Presented  by 

Thomas  «!•  Dailey 
C.   0.  P.  &  S.    »£ 


COLLEGE    OF    OSTEOPATHIC    PHYSICIANS 
AND  SURGEONS  •    LOS  ANGELES,  CALIFORNIA 


U33W-.J  /UiAdJ 


THE  PRINCIPLES  AND  PRACTICE 


OF 


HYDEOTHERAPT 


BY 

SIMON  BARUCH,  M.D. 

Professor  of  Hydrotherapy  in  Columbia  University  (College  of  Physicians  and  Surgeons),  New 
York ;  Medical  Director  of  the  Hydriatric  Department  of  the  Riverside  Association ;  Con- 
sulting Physician  to  the  J.  Hood  Wright  Memorial  (Formerly  Manhattan  General) 
Hospital ;  to  the  Monteflore  Hospital  for  Chronic  Invalids ;  Member  of  the 
New  York  Academy  of  Medicine ;  Formerly  Gynaecologist  to  the 
Northeastern  Dispensary ;  Physician  for  Eye,  Ear,  and  Throat 
to  the  Northwestern  Dispensary  of  New  York  City; 
Physician  and  Surgeon  to  the  New  York  Juve-       ^""' 
nile  Asylum,  and  Chief  of  the  Medical 
Staff  of  the  Monteflore  Home  for 
Chronic  Invalids 


THIRD  EDITION,  REVISED  AND  ENLARGED 


WITH    NUMEROUS    ILLUSTRATIONS 


NEW  YORK 
WILLIAM  WOOD  AND  COMPANY 

MDCCCCVIII 


COPYRIGHT,  1908, 
By  WILLIAM  WOOD  AND  COMPANY 


PREFACE  TO  THE  THIRD  EDITION. 


THE  necessity  for  a  special  work  on  hydrotherapy  still  appears  to 
be  urgent,  if  the  attention  this  subject  receives  in  the  average  text-book 
be  accepted  as  a  criterion.  One  of  the  latest  of  these  works  on  thera- 
peutics says  in  its  thirteenth  edition :  "  The  object  of  the  bath  is  the 
reduction  of  the  temperature,  and  unless  this  is  effected  no  good  re- 
sults." And  this  false  teaching  emanates  from  a  work  which  the  ma- 
jority of  students  use  as  a  text-book  and  whose  value  in  other  respects 
is  attested  by  its  popularity. 

The  author  will  complete  in  eighteen  months  a  half-century  spent 
in  the  study  and  practice  of  medicine.  During  the  first  half  of  this 
period  he  was  uninformed  on  hydrotherapy;  during  the  latter  half 
he  has  endeavored  to  study  and  utilize  water  as  a  remedial  agent. 
He  has  therefore  subjected  water  to  the  crucial  test  of  a  control  ex- 
periment. And  he  may  conscientiously  say  that  the  comfort  and  satis- 
faction which  the  addition  of  this  agent  to  his  therapeutic  resources 
has  afforded  him  in  the  amelioration  of  suffering  and  saving  of  lives 
warrant  him  to  devote  the  remaining  years  of  his  life  to  the  effort 
of  diffusing  a  better  acquaintance  with  this  neglected  therapeutic 
weapon  among  his  colleagues. 

When  an  eminent  clinical  teacher  like  Semmola,  whose  lectures  on 
therapeutics  were  translated  into  German  under  the  supervision  of  and 
with  a  preface  by  Nothnagel,  writes  of  hydrotherapy  "frequently 
real  marvels  of  restoration  in  severe  and  desperate  cases  have  been 
obtained  by  it,"  and  this  opinion  has  been  echoed  by  Kussmaul  in 
Germany,  Charcot  in  France,  and  our  own  Draper  and  others  of,  equal 
credibility  in  their  respective  countries,  who  were  not  specialists  in 
this  branch,  it  becomes  the  duty  of  every  conscientious  physician  to 
investigate  and  utilize  it.  To  facilitate  the  latter  this  work  has  been 
written  from  the  standpoint  of  the  family  and  hospital  physician. 
Each  edition  has  been  carefully  revised,  that  which  has  been  disproved 
has  been  eliminated,  and  all  modern  ideas  have  been  incorporated. 

It  has  been  the  aim  of  the  author  to  continue  in  the  third  edition 
the  attitude  ascribed  to  him  by  a  reviewer  of  the  German  translation 
in  the  Berliner  klinische  Wovhenschrift,  viz. ,  as  "  the  true  friend  at  the 
bedside  of  the  sick  and  suffering — a  friend  from  whom  one  may  draw 
counsel  on  all  difficult  questions  of  practice,  with  the  assurance  that 
only  that  which  has  been  proven,  sedulously  examined,  and  critically 
sifted  will  be  received  for  the  benefit  of  the  sick." 


21488 


iv  PREFACE  TO  THE  THIRD  EDITION. 

Since  the  last  edition  was  issued  an  era  in  hydrotherapy  has  been 
inaugurated  by  the  establishment  of  a  special  chair  on  this  usually 
neglected  subject  in  one  of  our  prominent  universities,  with  a  clinic 
for  individual  instruction  of  the  senior  students  and  other  conditions 
placing  hydrotherapy  on  an  equal  footing  with  other  important 
branches  of  instruction.  In  view  of  the  fact  that  the  excellent  exam- 
ple of  this  great  school  will  doubtless  be  emulated  by  many  other 
schools,  text-books  have  become  a  more  imperative  necessity. 

Recent  developments  in  our  magazine  literature  are  regarded  by 
the  author  as  the  mutterings  of  a  storm  that  may  sweep  over  the  medi- 
cal profession  ere  long,  and  repeat  the  disturbance  of  the  faith  in  the 
doctor  which  the  advent  of  that  class  of  empirics  who  call  themselves 
"Naturarzte"  stirred  up  in  Germany  in  the  latter  third  of  the  last 
century.  This  event  is  referred  to  at  length  in  the  history  of  hydro- 
therapy  in  Germany.  The  author  has  given  frequent  warnings  to  his 
colleagues  to  study  and  utilize  hydrotherapy  and  other  physical 
methods,  in  order  to  meet  the  encroachment  of  these  empirics. 

In  some  of  the  German  reviews  of  this  work  surprise  was  expressed 
that  the  author  continues  to  advocate  the  Brand  bath  in  typhoid  fever, 
although  it  had  fallen  into  "  innocuous  desuetude  "  in  the  country  of 
its  birth.  In  this  edition  the  author  has  endeavored  to  show  why 
American  physicians  have  adopted  this  method  with  zeal,  and  that  the 
most  eminent  teachers  still  utilize  it  because  it  saves  many  lives.  The 
author  feels  pride  in  this  achievement  of  American  medicine,  and  has 
continued  to  devote  large  space  to  the  elucidation  of  a  method  which 
illustrates  the  value  of  strict  compliance  with  technique. 

The  chapters  on  Phthisis  and  Insanity  have  been  enlarged  by  the 
addition  of  clinical  and  other  material.  In  these  diseases  hydro- 
therapy  has  won  its  greatest  triumphs  in  institution  practice,  because 
it  has  been  systematically  applied. 

The  author  would  reiterate  the  importance  of  studying  the  clinical 
histories  which  he  has  introduced  with  careful  exclusion  of  needless 
detail.  These  histories  are  not  mere  statements  of  the  patient's  con- 
dition and  progress;  their  chief  value  consists  in  suggestions  of 
changes  in  procedures  as  they  are  indicated  by  changing  conditions. 
The  latter  are  often  as  imperative  as  are  changes  in  drugs;  this  is 
illustrated  by  the  hospital  records  of  Case  V  on  page  331  and  Case  II 
on  page  329.  See  also  page  416.  Case  of  Chlorosis,  page  407. 

In  the  theoretical  portion  of  the  book  the  author  has  endeavored  to 
construct  a  theory  of  reaction  which  may  conciliate  the  contradictory 
views  of  hydrotherapeutists  and  present  a  clear  rationale  of  the 
action  of  water  in  health  and  disease. 

135  WEST  SEVENTY-THIRD  STREET. 


PREFACE  TO  THE  SECOND  EDITION. 


THE  author  views  with  satisfaction  the  rapid  rise  of  hydrotherapy 
since  the  publication  of  the  first  edition.  He  has  endeavored  in  the 
present  volume  to  eliminate  matter  which  was  required  in  the  first  to 
fortify  his  plea  for  the  more  universal  utilization  of  water  in  disease. 
The  entire  work  has  been  revised  and  much  new  matter  has  been 
added.  A  chapter  on  reaction  is  devoted  to  the  elucidation  of  the 
basic  principles  of  hydrotherapy  in  consonance  with  advanced  physi- 
ology and  the  most  recent  experimental  findings. 

A  chapter  on  insanity  has  been  added,  based  upon  the  recorded 
observations  of  practical  alienists  in  charge  of  large  asylums.  This 
chapter  not  only  illustrates  the  value  of  this  agent  in  these  ordinarily 
unsatisfactory  cases,  but  emphasizes  the  importance  of  trained  attend- 
ants and  exact  technique. 

The  author  has  long  urged  the  need  of  the  same  precision  in  the 
application  of  water  in  therapeutics  as  that  which  is  justly  regarded 
as  paramount  in  the  prescription  of  diet,  exercise,  rest,  and  medicinal 
agents.  The  present  volume  bears  ample  testimony  to  the  superiority 
of  methodical  hydrotherapy  over  the  slipshod  and  inexact  mode  of  its 
application,  long  in  vogue. 

As  stated  in  the  first  edition,  this  work  is  based  upon  observations 
of  a  general  practitioner  in  hospital  and  private  practice,  and  is  in- 
tended as  a  guide  to  that  numerous  class  of  his  colleagues  who  battle 
with  disease  and  death  in  the  patient's  home  or  in  general  hospitals. 
For  this  reason  he  would  urge  special  attention  to  the  brief  clinical 
histories  which  are  furnished  to  illustrate  the  need  of  individualization 
and  to  point  out  clearly  the  changes  demanded  by  fluctuations  in  the 
type  or  progress  of  each  case.  Since  therapeutic  effects  are  modified 
more  positively  by  modifications  in  the  technique  of  hydrotherapy  than 
are  the  effects  of  medicinal  agents  by  changing  the  dose,  it  becomes 
imperative  to  study  the  technique  of  every  procedure  as  modified  by 
existing  conditions.  The  clinical  histories  are  intended  to  familiarize 
the  practitioner  with  these  modifications. 

So  flexible  is  this  therapeutic  agent  that,  unlike  medicinal  reme- 
dies, it  may  be  utilized  to  meet  indications  which  seem  contradictory 
to  the  uninitiated.  The  histories  are  offered  as  guides  to  the  technique 


VI  PREFACE  TO  THE  SECOND  EDITION. 

in  varying  phases  of  disease.  Why  opposite  results  have  been  reached 
by  apparently  similar  uses  of  water  is  clearly  set  forth  in  the  chapter 
on  the  Hydriatric  Prescription,  which  is  intended  to  show  that  water 
is  as  capable  of  exact  dosage  as  any  other  remedial  agent,  and  that  the 
physician  may  readily  familiarize  himself  with  the  methods  for  attain- 
ing this  necessary  precision. 

Certain  long-established  errors  on  the  antithermic  uses  of  cold 
water  have  been  referred  to  in  the  chapter  on  Insolation,  and  the  clini- 
cal records  of  several  large  hospitals  have  been  cited  to  fortify  the 
author's  position  and  to  further  a  less  antithermic  and  more  successful 
therapy. 

Typhoid  fever  has  received  the  lion's  share  of  the  clinical 
chapters,  not  alone  because  of  its  frequency,  but  chiefly  because  the 
hydriatric  management  of  this  disease  serves  to  illustrate  the  rationale 
and  technique  of  cold  applications  in  the  most  convincing  manner  by 
observations  of  practical  clinicians  whose  acumen  and  skill  cannot  be 
doubted. 

While  the  author  should  have  preferred  to  use  the  Celsius  scale 
in  these  pages,  he  felt  constrained  to  adhere  to  the  Fahrenheit  scale, 
which  is  still  popular  in  this  country,  in  order  to  avoid  confusion. 
The  fallacy  of  axillary  and  mouth  thermometry  as  temperature  guides 
is  illustrated  by  striking  examples  obtained  from  otherwise  scientific 
institutions. 

In  every  part  of  the  work  the  author  has  endeavored  to  inculcate 
the  rationale  of  each  procedure,  and  detailed  the  methods  in  such 
manner  that  the  family  physician  may  utilize  the  latter  at  the  pa- 
tient's home  in  the  chronic  as  well  as  in  the  acute  cases,  and  thus  spare 
his  patients  the  discomfort  and  expense  of  removing  to  hydrothera- 
peutic  institutions. 

The  historical  epitome  purposes  to  awaken  his  colleagues  to  a 
realization  of  the  danger  which  by  reason  of  the  indifference  of  the 
majority,  as  Kussmaul  has  pointed  out,  threatens  them  and  their 
clientele.  Earnest  and  conscientious  investigation  of  the  claims  of 
hydrotherapy,  and  better  instruction  in  its  principles  and  technique 
are  urgently  demanded. 

The  author  feels  warranted  in  claiming  a  perfectly  judicial  attitude 
on  hydrotherapy,  because  he  did  not  begin  its  study  and  practice  un- 
til he  had  been  a  practitioner  fifteen  years,  and  because  he  has  sub- 
jected its  claims  to  the  crucial  test  of  observation  during  the  past 
quarter  of  a  century,  in  private,  hospital,  and  dispensary  practice. 

NEW  YORK,  Hotel  Majestic.  SIMON  BARUCH. 


PREFACE  TO  THE  FIRST  EDITION. 


DIFFERING  from  all  other  works  on  hydrotherapy,  this  book  is 
written  by  a  general  practitioner  for  the  guidance  of  his  colleagues. 

The  following  pages  represent  the  observations  of  the  author,  who 
has  labored  in  every  branch  of  medicine,  and  who  has  gathered  these 
data  from  a  private  and  hospital  practice  extending  over  a  third  of  a 
century,  and  more  recently  from  special  institution  practice.  The  lat- 
ter, extending  over  a  period  of  seven  years  and  furnishing  the  recorded 
details  of  over  one  hundred  thousand  hydriatic  treatments,  may  be 
confidently  offered  as  a  trustworthy  guide  in  the  hydrotherapy  of 
chronic  diseases,  while  the  former  is  regarded  by  the  author  as  equally 
trustworthy  as  a  guide  in  the  management  of  acute  diseases. 

It  is  not  the  purpose  of  the  author  to  write  a  panegyric  upon 
Hydrotherapy,  but  to  discuss  water  as  a  remedial  agent  precisely  as 
medicinal  remedies  are  discussed  in  the  text-books  on  therapeutics. 

The  first  part  of  the  book  deals  with  the  physical  properties  of 
water  and  its  mode  of  action  in  health;  the  laboratory  experiments 
upon  which  the  latter  is  based  being  freely  discussed.  The  second 
part  is  devoted  to  the  practice  of  hydrotherapy.  The  various  meth- 
ods of  applying  water  in  disease  are  minutely  described  and  illus- 
trated, the  rationale  of  each  procedure  is  discussed,  and  its  special 
therapeutic  indications  are  outlined. 

Having  mastered  the  technical  details,  the  reader  is  introduced  to 
the  practical  application  of  hydrotherapy  in  acute  and  chronic  diseases, 
in  order  to  familiarize  him  with  the  flexibility  of  this  potent  remedial 
agent.  The  clinical  histories  which  are  added  to  this  part  of  the  book 
are  specially  commended  to  the  attention  of  the  reader,  inasmuch  as 
they  illustrate  pratically  how  different  hydriatric  procedures  may  be 
adapted  to  varying  conditions  of  the  patient  and  his  malady.  That 
hydrotherapy  differs  materially  in  this  respect  from  medicinal  therapy 
will  be  made  evident  by  a  careful  reading  of  these  histories.  Every 
statement  of  the  author  will  be  found  supported  not  only  by  his  per- 
sonal observations,  but  also  by  the  published  testimony  of  acknowledged 
authorities  in  clinical  medicine.  The  opinions  of  specialists  in  hydro- 
therapy  have  been  avoided  as  far  as  possible,  because  these  are  often 
charged  with  unwarranted  enthusiasm  for  their  favorite  remedy. 

The  author  has  adopted  this  judicial  and  dispassionate  course,  be- 


Vlll  PREFACE   TO   THE   FIRST   EDITION 

cause  he  desires  to  disarm  prejudice  and  to  disseminate  a  more  exact 
knowledge  of  the  application  of  water  in  disease  among  medical  men, 
many  of  whom  appear  to  entertain  vague  ideas  on  the  subject. 

That  hydrotherapy  is  an  effective  agent  in  acute  diseases  is  begin- 
ning to  be  recognized  by  reason  of  the  success  attending  it  in  typhoid 
fever.  But  the  fallacious  idea  still  .prevails  that  chronic  diseases  must 
be  sent  away  from  home  in  order  to  obtain  good  results  from  hydro- 
therapy.  While  it  is  true  that  the  treatment  in  institutions  offers  the 
best  prospect  in  chronic  cases,  the  reason  lies  not  so  much  in  the  facili- 
ties offered  by  them  as  in  the  experience  and  consequent  skill  acquired 
by  physicians  from  the  large  clientele  of  such  institutions.  A  consid- 
erable proportion  of  the  most  prevalent  chronic  diseases  does  not  require 
institution  treatment;  nevertheless,  they  demand  a  careful  adjustment 
of  temperature,  duration,  and  technique  to  each  individual  case.  Such 
knowledge  may  be  as  readily  acquired  by  the  practitioner  as  is  that  of 
any  other  department  of  therapeutics. 

Having  mastered  the  technique  and  mode  of  action  of  hydriatric  pro- 
cedures, the  educated  physician  will  discover  that  he  may  often  obtain 
as  good  results  from  the  simplest  methods  as  from  those  requiring  more 
technical  skill. 

To.  afford  this  information  in  a  concise  and  practical  form  is  the 
object  of  this  work ;  the  author,  himself  a  general  practitioner,  believes 
that  he  appreciates  the  needs  of  his  colleagues. 

The  chapter  on  the  hydriatric  prescription  is  devoted  to  an  exposi- 
tion of  the  prevalent  fallacy  that  water  is  so  simple  and  innocuous  a 
remedy  that  it  may  be  applied  with  less  regard  for  precision  than  the 
physician  is  wont  to  exercise  in  prescribing  medicinal  remedies.  The 
author  has  endeavored  to  inculcate  by  striking  examples  the  importance 
of  exactness  in  prescribing  and  executing  hydriatric  procedures. 

The  concluding  chapter  points  out  the  lessons  derived  from  the  his- 
tory of  hydrotherapy.  It  aims  to  show  the  need  of  instruction  in 
hydrotherapy  in  our  medical  schools,  in  order  that  this  valuable  rem- 
edy may  be  wrested  from  the  laymen  and  empirics,  who  have  stolen  it 
from  medical  men,  and  who  alienate  the  latter  by  perverting  it  for  their 
mercenary  ends. 

The  addition  of  hydrotherapy  to  the  curriculum  of  our  medical 
schools,  as  is  done  in  the  universities  of  Vienna  and  Heidelberg,  would 
arm  the  young  practitioner  with  a  much-neglected  weapon,  whose  power 
is  amply  demonstrated  in  these  pages. 

The  author  would  ask  the  earnest  attention  of  teachers  of  clinical 
medicine  to  the  concluding  chapter  of  the  book. 


CONTENTS. 


PAGE 

Introduction.     Definitions, 1 

CHAPTER   I. 

The  Physiological  Effects  of  Water,      ........       3 

Anatomy  and  Physiology  of  the  Skin, 4 

CHAPTER  II. 
Function  of  the  Skin, 21 

CHAPTER  III. 
Physical  Properties  of  Water, 31 

CHAPTER  IV. 

Rationale  of  Action  of  Water  in  Health, 33 

Effect  of  Hydriatic  Applications  upon  the  Distribution  of  Blood,          .         .     34 
"       "  "  "  on  the  Pulse,      ......     52 

"  on  Blood  Pressure,     .         .         .        .         .50 

"       "  "  "  Composition  of  Blood,        ....     57 

Changes  in  Lymph  Movement,  .         .         .70 
Influence  of  Hydriatic  Applications  upon  the  Respiration,  .        .        .         .     71 

"   the  Muscular  System,  .         .         .75 
"   Tissue  Change,      .         .        .         .     79 

"          "  "         Procedures  on  Temperature,    .         .         .         .         .90 


PAKT   II. 

CHAPTER  V. 
Reaction,      .         .         .         .         .         .        .        .         .         .         .         .         .96 

CHAPTER   VI. 

The  Practice  of  Hydrotherapy, 103 

Ablution, 104 

Half-Bath, .         .108 

Affusion,       .         .         .         .         .         .         .         .         .        .         .         .         .110 

Sheet  Bath 115 

Drip  Sheet, 118 

Cold  Rub, 123 

Wet  Pack, 124 


X  CONTENTS. 

PAGE 

Wet  Compress,       ............  140 

Chest  Compress,    ............   142 

Precordial  Compress, .  160 

CHAPTER   VII. 

The  Full  Bath, 164 

The  Cold  Friction  Bath, 165 

Therapeutic  Indication  of  the  Cold  Friction  Bath,        .....  187 

Fevers, 187 

Objections  Urged  against  the  Brand  Method, 211 

Contraindications  to  the  Cold  Bath, .         .  224 

CHAPTER   VIII. 

The  Warm  Full  Bath, 220 

The  Continuous  or  Hammock  Bath,      ........  239 

Localized  Continuous  Baths,         .........  250 

CHAPTER   IX. 
The  Douche, 253 

CHAPTER  X. 
The  Hip  Bath, 244 

CHAPTER  XL 

Irrigation, 272 

Lavage, 272 

Enteroclysis,         ............  284 

Irrigation  of  the  Urethra  and  Bladder,          . 297 

Vaginal  Irrigation,        .         .         .         .--.".»         .         ...        .         .         .  301 

CHAPTER   XII. 

Methods  of  Cooling  and  Heating  Internal  Parts,  ......  304 

The  Prostatic  Cooler,    .         .         .         .'...,..         .         .         .         .         .  304 

The  Perineal  Douche, 306 

Steam  as  a  Therapeutic  Agent, 307 

"     Styptic, .."       .         .         .         .         .  308 

CHAPTER  XIII. 

The  Internal  Use  of  Water,  .         .         .         .    ,     .         .         .         .         .314 

Therapeutic  Indications,       .         .  .         .         .         .         .         .         .317 

CHAPTER   XIV. 

Practical  Application  of  Hydrotherapy  in  Acute  and  Chronic  Diseases,        .  320 
Hydrotherapy  of  Typhoid  Fever,          .         .         .         .         .         .         .         .321 

Diagnostic  Bath,   . ;         .321 


CONTENTS.  xi 

CHAPTER   XV. 

PAGE 

The  Exanthemata,        ...........  335 

Measles,        .....'.-....  .  335 

Scarlatina.    ........  .         .  338 

CHAPTER  XVI. 

Pneumonia,  .......        t        ....  345 

"  of  Children,      ....  .....  349 

"  Adults,          .         .         .         . 353 

CHAPTER  XVII. 

Entero-Colitis,      .  .    - .        .366 

CHAPTER  XVIII. 
Asiatic  Cholera,    .  .-         .  372 

CHAPTER  XIX. 
Insolation,  Sunstroke, 379 

CHAPTER  XX. 
The  Hot-Air  Bath,        .        .        .        .        .        .        .        .....        .387 

CHAPTER  XXI. 

Hydrotherapeutic  Apparatus  for  Hospitals,  Asylums,  and  Other  Institutions,  393 

CHAPTER  XXII. 

Chronic  Diseases, "...  403 

Anaemia  and  Chlorosis,          ..........  403 

CHAPTER  XXIII. 

Phthisis, .  409 

Diabetes, ...  425 

CHAPTER  XXIV. 
Malarial  Diseases, 426 

CHAPTER  XXV. 

Neurasthenia,        ........        ,  •  432 

Neuralgia,     .........  •  447 

Hysteria, .  .  454 

CHAPTER  XXVI. 

Chronic  Rheumatism  and  Gout,   ......  .  462 

CHAPTER   XXVII. 
Dyspepsia,    .............  471 


xii  CONTENTS. 

CHAPTER  XXVIII. 

PAGB 

Insanity, 497 

CHAPTER  XXIX. 

The  Hydriatric  Prescription, 505 

CHAPTER  XXX. 

Historical  Epitome, **" 

Hydrotherapy  in  Germany, 519 

"   Italy, 524 

"  "  France, 524 

"  "  England, 526 

"  America, 528 

Conclusion, °"*i 

Necessity  for  Instruction  in  Hydrotherapy 533 

INDEX, S37 


THE 

PRINCIPLES  AND  PRACTICE  OF  HYDROTHERAPY. 


INTRODUCTION. 

HYDROTHERAPY. 

Definition. — Hydrotherapy,  as  its  derivation  from  udtap,  water,  and 
0?f>aTT£ua>,  to  heal,  indicates,  may  be  defined  as  the  method  of  applying 
water  in  disease.  Some  physicians  have  endeavored  to  restrict  the 
term  to  the  remedial  use  of  cold  water  alone,  and  this  is  not  an  un- 
common error.  An  excellent  medical  dictionary,  now  in  considerable 
use,  defines  hydrotherapeutics  to  be  the  application  of  cold  water  to 
disease.  If  those  who  are  familiar  with  the  derivation  of  the  term 
commit  so  serious  an  error,  it  is  not  surprising  that  erroneous  views  of 
the  application  of  water  in  disease  are  general  among  the  profession 
and  lay  people.  The  idea  probably  originated  with  the  hydropaths, 
who  claim  Priessnitz,  the  apostle  of  cold  water,  as  their  leader.  This 
empiric  has  doubtless  given  a  strong  impetus  to  the  popularization  of 
cold  water  in  disease.  Indeed,  his  life  and  labors  form  a  remarkable 
chapter  in  the  history  of  this  subject,  and  will  be  referred  to  more 
fully  in  another  part  of  this  work. 

It  will  surely  inure  to  the  progress  and  development  of  hydro- 
therapy,  i.e.,  the  scientific  application  of  water  in  disease,  if  this  false 
conception  of  its  being  a  cold-water  treatment  be  removed  from  the 
minds  of  the  profession  and  the  people.  There  seems  to  exist  in  the 
human  mind  a  strong  feeling  of  repulsion  against  cold  baths,  wet 
packs,  and  other  hydriatric  procedures.  The  former  conjure  up  in  the 
mind  of  the  timid  practitioner  vague  apprehensions  of  shock  and  heart 
failure;  the  latter  remind  him  of  damp  sheets  bearing  rheumatism 
and  colds  in  their  train.  The  reader  who  shall  follow  these  pages 
will  find  in  them  ample  illustrations  of  the  untenability  and  the 
absurdity  of  such  views. 

Hydrotherapy  includes  the  application  of  water  in  any  form  from 
the  solid  and  fluid  to  vapor  ;  from  ice  to  steam,  internally  and  exter- 
nally. The  recently  discovered  styptic  action  of  steam,  the  well-known 
1 


2  THE  PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

• 

aseptic  effects  of  hot  water  in  surgery ;  its  resorbent  use  in  gynaecology 
and  surgery ;  its  application  in  gastric,  rheumatic,  and  intestinal  troubles 
and  in  meningitis;  its  value  in  gastric  catarrh,  render  hot  water  as  im- 
portant a  hydriatric  agent  as  is  cold  water. 

Hydrotherapy  does  not,  however,  include  the  use  of  mineral  waters 
when  these  depend  upon  their  mineral  constituents  for  therapeutic 
efficacy  (which,  by  the  way,  is  rarely  the  case).  While  these  mineral 
waters  are  quite  as  valuable  as  is  plain  water  in  all  the  procedures  of 
hydrotherapy,  if  they  possess  the  proper  temperature,  etc.,  the  mineral 
constituents  do  not  often  add  to  the  effects  produced,  inasmuch  as  the 
latter  are  the  result  of  the  judicious  adaptation  of  the  mechanical  and 
thermic  influence  of  water  alone. 

A  clear  conception  of  this  subject  is  important  at  the  outset.  It 
may,  therefore,  be  stated  that  hydrotherapy  depends  upon  the  me- 
chanical and  thermic  action  of  water  in  disease,  irrespective  of  the 
source  from  which  it  may  be  obtained.  Balneology  depends  upon  the 
chemical  and  diluent  action  of  mineral  waters,  the  effects  of  which  are 
greatly  modified  by  and  depend  almost  entirely  upon  the  source  from 
which  they  are  derived. 

Hydropathy  is  a  method  of  practice  adopted  by  certain  empirics 
who  base  their  results  chiefly  upon  the  effect  of  cold  water.  Other 
terms,  referring  to  the  subject  in  general,  are  the  adjectives  hydriatric 
and  hydriatic.  Hydriatric  is  derived  from  u<5«y>,  water,  and  larpta, 
medical  treatment ;  it  is  a  short  and  equally  expressive  substitute  for 
the  adjective  hydrotherapeutic.  We  may  correctly  speak  of  hydriatric 
procedures  or  hydriatric  institutions,  but  the  term  cannot  be  applied 
to  water  applications  made  in  physiological  experiments. 

Hydriatic  is  an  adjective  in  common  use,  qualifying  nouns  con- 
nected with  the  use  of  water  in  medicine  or  for  other  purposes.  Its 
correct  derivation  I  have  been  unable  to  obtain.  It  is  the  close  equiva- 
lent of  aquatic.  It  may  obviously  be  applied  to  procedures  as  hydriatic 
measures,  or  water  applications  in  health,  but  its  use  is  incorrect  when 
applied  to  institutions,  etc.  This  word  should  be  banished  altogether 
when  referring  to  the  remedial  application  of  water.  The  word  hy- 
driatric is  more  expressive  and  clearly  indicates  that  water  is  used  for 
remedial  purposes.  It  is  proper  to  use  it  in  connection  with  measures, 
procedures,  or  prescriptions,  but  it  would  obviously  be  tautology  to 
use  it  in  connection  with  treatment. 


CHAPTER    I. 

THE  PHYSIOLOGICAL  EFFECTS  OF  WATER. 

As  a  basis  for  the  proper  understanding  of  the  uses  and  effects  of 
water  in  diseased  conditions,  it  is  important  to  study  and  thoroughly 
master  its  action  in  health.  Wilhelm  Winternitz,  of  Vienna,  has 
made  the  expansion  of  hydrotherapy  into  a  branch  of  scientific  thera- 
peutics the  mission  of  his  life.  To  his  initiative  may  be  traced  al- 
most all  the  advances  that  have  been  made  in  this  important  subject. 
He  endeavored  to  impress  upon  the  medical  profession  the  idea  that 
methodical  and  physiological  observation  must  be  utilized  as  the  basis 
of  hydrotherapy.  Deviating  from  the  prevalent  comments  resorted  to 
in  balneological  writings,  he  banished  such  expressions  as  "  enhancement 
of  activity  of  functions,"  "  favorable  changes  in  the  gastric  and  pulmo- 
nary nerves,"  "  agreeable  stimulation  of  the  circulation,"  "  improvement 
of  the  blood."  For  these  he  proposed  to  substitute  actual  demonstra- 
tions by  experimental  processes  of  the  effect  of  water  in  health  and  dis- 
ease. Thus  a  grand  impetus  was  given  to  the  subject,  an  impetus  whose 
influence  will  be  long  discernible.  Indeed,  no  writer  in  this  field  of 
therapeutics  can  add  much  to  the  thorough  and  masterly  presentation 
of  the  scientific  side  of  this  subject.  We  [may,  however,  amplify  the 
observations  of  Winternitz,  and  add  confirmation  by  experiments  and 
clinical  results  of  the  claims  he  has  set  forth  for  the  remedial  value  of 
water,  by  applying  the  findings  of  recent  laboratory  experiments  to 
the  rational  explanation  of  its  action  in  health  and  disease.  Differ- 
ing from  all  writers  who  have  preceded  him,  and  from  many  who 
have  followed  him,  the  writings  of  Winternitz  are  not  panegyrics  upon 
the  unfailing  virtues  of  this  remedial  agent,  but  rather  ingenious,  at 
times  classical,  demonstrations,  often  mingled  with  confessions  of  de- 
fects in  our  knowledge,  and  strivings  to  amplify  the  latter  by  pointing 
them  out  in  the  clearest  manner. 

Since  the  chief,  though  not  by  any  means  all,  effects  of  hydro- 
therapy  concern  the  thermic  and  mechanical  action  of  water  upon  the 
cutaneous  surfaces  of  the  body,  it  becomes  necessary  to  study,  1,  the 
anatomical  construction  and  physiology  of  the  skin,  from  a  hydriatric 
standpoint ;  and,  2,  the  physical  properties  of  water  which  render  it 
capable  of  producing  these  effects. 


THE   PRINCIPLES   AND    PRACTICE   OF   HYDROTHERAPY. 


ANATOMY  AND  PHYSIOLOGY  OF  THE  SKIN. 

Although  an  intimate  knowledge  of  this  subject  is  important  to  the 
hydrotherapist,  it  is  not  my  purpose  to  enter  into  so  minute  and  de- 
tailed an  account  of  the  anatomy  of  the  skin  as  would  be  required  for 
the  purposes  of  dermatology.  In  connection  ivith  hydrotherapy  it  is 
only  necessary  to  study  briefly  the  anatomical  structure  of  the  skin  for 
purposes  of  furthering  a  correct  understanding  of  its  functions.  Those 
portions  of  the  skin  which  contain  the  blood  and  nerve  supplies  will, 
therefore,  interest  us  most.  Their  distribution  over  enormous  areas 
and  their  interdependence,  direct  and  indirect,  with  almost  every 
organ  in  the  human  body,  lend  to  the  subject  of  the  nerves  and  blood- 
vessels of  the  skin  paramount  import  to  the  student  of  hydrotherapy. 

It  appears  to  the  author  that  a  more  careful  and  elaborate  discus- 
sion of  these  structures  than  is  usually  accorded  to  them  in  the  works 
on  hydrotherapy  would  be  of  practical  value. 

The  epidermis  is  so  constructed  anatomically  that  it  serves  as  a 
protecting  layer  to  the  more  delicate  and  sensitive  structures  lying 
immediately  beneath  it. 

The  cutis  vera  consists  of  the  white  fibrous  and  yellow  elastic  con- 
necting tissue,  forming  bundles  which,  in  the  upper  layers,  are  so 
thickly  and  closely  aggregated  that  they  appear  like  felt.  This  con- 
tains the  papillae,  whose  number  is  enormous.  In  the  deeper  layer, 
the  stratum  reticularis,  the  elastic  fibres  form  a  network  which,  by 
its  disposition,  lends  itself  to  the  special  functions  of  the  skin  in  the 
various  parts  of  the  body,  and  by  its  structure  admits  the  blood 
vessels  and  nerves,  which  lend  to  the  skin  the  most  important  functions 
connected  with  hydrotherapy.  The  muscular  fibres  of  the  skin  are  of 
the  involuntary  variety.  They  form  a  network  in  almost  all  parts  of 
the  skin  except  the  palm  of  the  hand  and  sole  of  the  foot;  they  are 
found  in  great  abundance  in  the  scrotum,  penis,  and  nipple.  Besides 
these  muscular  fibres,  the  arrectores  pili  form  a  tense  structural  union 
with  the  parts  of  the  cutis  vera  which  lie  between  the  papillary  tissue 
and  portions  of  the  hair  follicles.  Sappey  says  that  this  type  of  cuta- 
neous muscle  is  developed  in  the  pars  papillaris  from  several  tuft-like 
muscle  bundles,  which  in  their  passage  through  the  pars  reticularis 
unite  into  one  or  more  larger  flat  bundles.  Very  often  the  arrectores 
pili  are  found  to  be  arranged  in  such  manner  that  the  hair  follicle 
appears  to  be  inserted  in  the  angle  between  the  hair  and  the  muscle  cord. 
In  many  parts  of  the  skin,  as  on  the  back,  cheeks,  and  forehead,  smooth 
muscular  fibres  are  present  in  the  form  of  a  network  which,  arising 
from  the  pars  papillaris,  terminates  in  the  upper  two-thirds  of  the 


THE   PHYSIOLOGICAL    EFFECTS   OF   WATER.  5 

pars  reticularis.  The  direction  in  which  these  muscular  fibres  contract, 
like  that  of  the  arrectores  pili,  is  diagonal  through  the  thickness  of  the 
skin.  They  are  really  diagonal  skin  muscles.  The  function  of  the 
muscular  fibres  which  are  found  in  the  largest  part  of  the  cutaneous 
area  is  to  render  the  skin  tense  in  horizontal  or  diagonal  directions. 
They  are  regarded  as  a  whole  by  Unna,  who  gives  them  the  appella- 
tion of  oblique  tensors  of  the  cutis,  the  real  origin  and  ending  of  which 
are  in  the  elastic  tissue  (which  Tomsa  compares  to  the  tendons  mother 
parts),  and  through  the  latter  in  the  entire  skin.  That  the  tension  of 
the  skin  produced  by  its  muscular  structure  and  elastic  network  is 
really  subject  to  temperature  changes  may  be  observed  very  readily  in 
the  dartos  of  the  scrotum.  In  the  latter,  medium  tension  is  produced 
by  a  medium  temperature,  relaxation  by  a  higher  temperature,  while  a 
lower  temperature  produces  contraction,  which  is  evidenced  by  its  being 
drawn  up.  In  hairy  parts  this  contraction  produces  the  well-known 
cutis  anserina.  Tomsa  has  clearly  shown  that  when  the  arrectores  pili 
contract  they  draw  the  skin  from  without  inward,  embracing  in  their 
action  the  terminal  portion  of  the  blood  supply  of  the  papillary  body,  and 
thus  they  empty  the  smallest  blood-vessels  in  such  manner  as  may  best 
conduce  to  normal  circulation.  There  are  many  proofs,  according  to 
Unna,  that  the  action  of  the  arrectores  muscles  is  not  confined  to  the 
hair  follicles,  but  that  they  are  intimately  invoiced  in  the  movement  of 
the  blood  and  lymph. 

This  anatomical  construction,  by  which  the  cutaneous  muscles  are 
surrounded  in  their  entire  extent  by  a  woof  of  elastic  fibres  which  are 
connected  with  each  other  and  with  the  tendinous  formations  existing 
in  the  skin,  renders  it  plain  that  a  shortening  or  tension  of  the  mus- 
cular fibres  always  simultaneously  contracts  the  elastic  apparatus 
which  is  woven  around  their  entire  extent.  This  explains  the  vital 
import  of  the  contractility  of  the  skin  when  exerted  upon  the  small  blood- 
vessels contained  in  it.  Inasmuch  as  the  condition  of  tension  of  the 
skin  may  thus  be  readily  varied  in  the  most  direct  manner  by  reason 
of  the  universal  presence  of  the  elastic  fibres,  and  inasmuch  as  muscu- 
lar coats  are  either  absent  in  the  vessels  of  the  skin  or  are  feebly  de- 
veloped, these  structures  really  perform  the  function  of  an  inhibitory 
apparatus  which  distributes  uniformly  pressure  and  motion,  and  en- 
ables the  oblique  muscular  fibres  which  are  embedded  in  the  skin  to  regu- 
late to  a  certain  extent  secretion  and  circulation,  the  movement  of 
lymph,  and  consequently  the  nutrition.  The  functional  interdepend- 
ence of  the  muscular  and  elastic  fibres  in  the  skin,  which  has  long 
been  recognized,  is  evidenced  here  by  the  fact  that  those  parts  which, 
like  the  palms  of  the  hands,  the  soles  of  the  feet,  the  nose,  show  the 
smallest  quantity  of  muscular  fibres  also  possess  the  smallest  elastic 


6  THK   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

fibres.  Both  of  these  parts  appear  simultaneously  in  the  first  six  or 
seven  months  of  foetal  life  (Unna). 

It  is  evident  that  a  recognition  of  the  contractility  with  which  the 
elastic  and  muscular  apparatus  of  the  skin  is  endowed  furnishes  the 
hydrotherapist  a  clew  to  most  of  the  functions  of  the  skin. 

Blood-  Vessels. — The  papillae  contained  in  the  upper  layer  of  the 
cutis  show  fine  capillary  loops,  or  blood-vessels,  which  rise  perpen- 
dicularly to  the  near  vicinity  of  the  epidermis,  nourishing  it  and 
furthering  exchange  of  gases  and  secretion  of  the  aqueous  portions  of 
the  perspiration.  These  capillary  loops  consist  of  an  arterial  and  a 
venous  portion,  which  combine  a  short  distance  below  the  point  of  the 
papillae,  and  which  run  either  straight  or  form  loops,  as  they  may  be 
filled  with  blood  or  compressed  by  the  papillae.  The  loop  may  be  so 
filled  with  blood  that  it  may  double  and  fold  over  in  spiral  windings 
until  it  occupies  almost  the  entire  space  of  the  papilla.  This  capacity 
for  increasing  or  diminishing  the  size  of  the  capillary  loops  furnishes  an 
important  agency  by  which  hydrotherapy  may  affect  the  circulation. 
The  blood-vessels  of  the  skin  differ  greatly  with  the  locality  and  func- 
tions of  the  part.  They  run  either  in  perpendicular  or  in  radiating 
loops  to  the  surface,  as  in  the  palms  of  the  hands,  ending  in  a  circular 
arrangement  of  the  numerous  branches,  or  they  are  drawn  into  a  flat 
arrangement  by  the  densely  contracted  bundles  of  elastic  fibres.  The 
horizontal  branching  of  these  partly  oblique  and  partly  perpendicular 
vessel  loops  is  found  chiefly  in  two  regions :  at  the  border  and  between 
the  true  cutis  and  the  subcutaneous  tissue,  or  between  the  border  of 
the  former  and  the  papillary  body.  The  terminal  branches  of  the 
capillaries  which  lie  beneath  the  capillary  body  consist  of  numerous 
tubules,  forming  a  wide-meshed  arterial  network,  whose  long  axis 
adapts  itself  to  the  direction  of  the  folds  of  the  epidermis.  From  this 
arises  for  each  vessel  papilla  a  rolled-up  arterial  capillary  which  is 
looped  in  order  to  form  the  more  winding  venous  capillary.  All 
the  venous  capillaries  of  the  papillary  body  unite  in  a  dense,  narrow- 
meshed  capillary  network  on  a  line  with  the  arterial  capillaries ;  from 
these  the  larger  veins  issue  which  pass  through  the  cutis  in  the  same 
direction  as  the  arteries.  All  the  vessels  of  the  papillary  tract, 
as  also  the  larger  branches  which  pass  through  the  skin,  consist  of 
only  an  endothelial  tube,  to  which  are  added  a  very  insignificant  media 
and  adventitia  in  the  vicinity  of  the  subcutaneous  tissue.  Hence 
their  character  is  chiefly  capillary.  The  arteries  are  narrow,  the  veins 
relatively  very  wide,  a  difference  which  increases  with  the  thickness 
of  the  epidermis  (Unna). 

The  papillary  blood  tract  enters  the  deeper  layer  of  the  cutis  vera 
at  several  points,  and  supplies  the  follicles,  glands,  and  oblique  mus- 


THE   PHYSIOLOGICAL   EFFECTS  OF  WATER.  7 

cular  fibres.  Beneath  the  papillary  layer  is  found  an  area  the  extent 
of  which  corresponds  with  the  thickness  of  the  cutis,  and  which  is  not 
well  supplied  with  blood-vessels. 

The  fibrous  layers  of  the  coriura  have  no  capillaries,  but  at  the 
border  lines  between  the  corium  and  the  subcutaneous  tissue  the  most 
abundant  supply  of  blood-vessels  is  met.  From  the  minute  arterial 
trunks  separate  branches  are  seen  to  arise  and  pass  to  the  whole 
papilla,  surrounding  the  latter  with  a  capillary  loop.  Every  sebace- 
ous gland,  also,  has  a  delicate  capillary  network,  which  forms  a  com- 
plete plexus  where  these  canals  are  in  close  proximity.  Branches 
from  this  plexus,  forming  delicate  though  dense  capillary  networks, 
also  are  seen  within  the  small  fat  flaps.  In  the  capillaries  permeating 
the  skin  the  elastic  coat  is  absent,  being  supplied  by  the  elastic  fibres 
of  the  skin  itself.  Meissuer  *  says  that  "  these  elastic  fibres  form  a 
firm  membrane  around  the  vessels ;  they  oppose  the  activity  of  the 
vasoconstrictors  and  support  the  vasodilators,  whose  power  is  much 
less.  They  also  surround  the  bundles  of  striated  muscle  fibres. 
When  the  latter  contract  the  former  are  stretched  and  thus  support 
the  muscular  fibres,  which  when  stretched  receive  no  antagonistic  pull 
because  of  their  being  suspended  (i.e.,  not  attached  to  firm  structures). 
They  also  protect  the  vessels  against  pressure  from  the  surrounding 
structures."  This  intimate  association  of  the  elastic  fibres  with  the 
blood-vessels  of  the  skin  would  indicate  that  they  are  intended  to  sub- 
stitute partially  at  least  the  action  of  muscular  fibres,  which  are  absent 
in  these  fine  vessels.  This  is  corroborated  by  the  fact  that  when,  in 
senile  degeneration  and  alcoholism,  the  microscope  detects  atheroma- 
tous  degeneration  in  the  vessels,  the  elastic  fibres  of  the  skin  are  ab- 
sent. In  fact,  according  to  Meissner,  these  elastic  fibres  begin  to  dis- 
appear when  the  vessels  are  becoming  rigid,  i.e.,  before  atheromatous 
changes  have  taken  place. 

With  the  exception  of  the  isolated  branches  supplying  the  whole 
papillae,  the  horizontal  distribution  of  the  vascular  branches  may  be 
said  to  keep  chiefly  within  the  two  border  lines  of  the  cutis  vera. 
The  form  of  distribution  of  vessels  in  the  adult  depends  upon  the  de- 
velopment of  the  thickness  of  the  corium.  As  the  subcutaneous  fat 
increases,  the  upper  portion  of  the  fat  cushion  is  supplied  by  the 
cutaneous  layer  of  the  muscular  fascial  vessels.  The  papillae  contain- 
ing tactile  corpuscles  have  no  blood-vessels. 

The  Physiology  of  the  cutaneous  circulation  is  a  subject  which  has 
not  received  sufficient  attention  either  from  physiologists  or  from  hydro- 
therapists.  The  author  has  long  held  that  it  would  be  impossible  for 
the  heart  to  propel  a  viscid  fluid  like  the  blood  through  the  fine  peri- 

*  Deutsche  Medizinal-Zeitung,  March  5th,  1896. 


8  THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

pheral  vessels,  unless  the  latter  were  endowed  with  propulsive  power 
which  aids  in  furthering  the  flow  of  the  blood  onward.  In  explain- 
ing the  rationale  of  the  Brand  bath  in  typhoid  fever,*  of  the  cold  chest 
compresses  in  pneumonia,  f  and  of  the  Nauheim  baths,  J  the  author  has 
emphasized  this  view,  which  was  derived  from  clinical  observation  en- 
tirely. The  anatomical  structure  of  the  skin,  consisting  mostly  of  a 
mesh  of  blood-vessels  interwoven  with  and  held  by  contractile  tissues, 
would  indicate  that  the  circulation  in  the  former  depends  upon  the 
functional  capacity  of  the  latter.  It  is  of  great  moment  to  ascertain 
how  smooth  muscular  fibres  are  affected  by  thermic  influences  and  other 
irritants.  Colin  Stewart  ||  offers  some  valuable  observations  on  the 
mammalian  smooth  muscles.  He  experimented  on  the  muscles  of  the 
cat's  bladder.  He  concludes :  "  Considering  the  whole  process  from 
the  standpoint  of  the  condition  of  the  muscle  at  the  body  temperature, 
it  may  be  said  that  cold  produces  an  increase  of  tonus,  while  heat 
gives  first  a  slight  relaxation,  then  a  marked  increase  in  tone,  when 
the  temperature  is  above  40°  (104°  F. ).  Then  shortening  once  more 
appears,  until  the  temperature  is  raised  to  53°  (127.4°  F.),  at  which 
temperature  the  muscle  dies." 

Stewart  therefore  confirms  what  Sartoli,§  Schultz,^T  and  Wood- 
ward **  have  observed  on  the  action  of  temperature  on  the  smooth  mus- 
cles of  cold-  and  warm-blooded  animals.  Schultz  has  demonstrated 
that  the  temperature  effect  is  exerted  upon  the  ganglia  in  the  muscle, 
and  not  on  the  muscular  fibre.  When  he  paralyzed  the  ganglia  by  atro- 
pin  or  cocain  the  muscles  failed  to  respond  to  thermic  irritation,  al- 
though they  still  responded  to  electrical  stimuli 

It  is  gratifying  to  the  author  to  discover  confirmation  of  this  view  by 
the  studies  of  Dr.  Woods  Hutchinson,  Professor  of  Comparative  Physi- 
ology in  the  University  of  Buffalo,  and  to  whom  I  am  indebted  for  ad- 
vance sheets  of  his  article  in  the  Boston  Medical  and  Surgical  Journal, 
November,  1897.  The  ingenuity  of  this  author  has  coined  a  word 
which  is  expressive  of  the  propulsive  action  of  the  cutaneous  vessels. 
He  writes  of  the  "skin  heart"  as  a  factor  in  the  human  circulation. 
While  modestly  claiming  that  he  is  in  a  position  little  more  than  to 
raise  the  question,  he  believes  that  the  minute  cutaneous  vessels  are 
capable  of  rhythmic  contraction.  As  Wesley  Mills  aptly  expresses  it, 

*  "  Uses  of  Water  in  Modern  Medicine,"  1390. 

f  Medical  News,  January,  1897. 

j Hare's  "System  of  Therapeutics,"  vol.  iv.,  p.  34. 

I  Am.  Jour.  Physiology,  1900,  iv.,  p.  185. 

§  Archiv.  Italienne  de  Biologie,  vol.  iii. 

IT  Archiv  f.  Anat.  u.  Physiologic,  1897,  p.  307. 

**  Am.  Journal  of  Physiology,  1899,  p.  26. 


THE   PHYSIOLOGICAL   EFFECTS   OF   WATER.  £ 

"An  inherent  tendency  to  rhythmic  contraction  all  through  the  vascu- 
lar system,  including  the  vessels,  must  be  taken  into  account."* 

"  We  have  long  been  conscious  of  the  utter  inadequacy  of  most 
of  the  explanations  of  the  extraordinarily  tonic  and  beneficial  effects 
of  bathing  or  splashing  the  surface  of  the  body  with  cold  water.  The 
familiar  'reaction  theory'  has  beeu  growing  more  threadbare  every 
year ;  for,  if  it  simply  consists  in  throwing  more  work  upon  an  already 
exhausted  or  overloaded  organ,  its  ultimate  effect  would  necessarily  be 
that  of  the  boyish  attempts  to  lift  one's  self  by  one's  boot-straps;  not 
that  this  element  does  not  play  some  part  in  the  reaction,  but  that  it  is 
utterly  inadequate  to  account  for  the  general  glow  of  satisfaction,  the 
feeling  of  comfort  and  permanently  tonic  effect,  which  are  brought 
about  by  this  simple  but  wonderfully  effective  means.  Why  the  blood 
should  remain  for  not  merely  minutes,  but  even  hours,  in  the  superfi- 
cial vessels  with  less  effort  than  before  the  plunge  or  splashing,  is,  of 
course,  hardly  to  be  accounted  for  simply  by  any  tonic  effect  upon  the 
heart  or  central  nervous  system.  But  when  this  remedy  began  to  be 
systematically  applied  in  therapeutics,  the  gap  between  the  theory  and 
the  results  became  wider  still.  In  the  Brand  treatment  of  typhoid 
fever,  for  instance,  while  we  were  at  first  inclined  to  regard  almost 
the  whole  of  its  beneficial  effect  as  due  to  a  mere  mechanical  lowering 
of  the  temperature  and  quickened  escape  of  abnormal  bodily  heat,  one 
after  another  of  our  clinicians  has  come  to  the  conclusion  that  this  is 
one  of  the  least  of  its  beneficial  effects,  and  that  the  singularly  tonic 
effect  which,  as  it  has  been  expressed,  is  produced  upon  the  heart  and 
nervous  system  and  the  renal  excretion  is  the  central  factor  in  its 
wonderful  power.  All  the  leading  authorities  upon  this  method  of 
treatment — Baruch,  Osier,  Siehler,  Stockton — have  expressed  them- 
selves most  definitely  on  this  effect. 

"  Still  more  recently,  in  a  widely  divergent  realm  of  therapeutics, 
the  method  is  equally  marked  and  with  even  more  surprising  results, 
first,  in  the  treatment  of  the  toxsemic  heart  failure  or  pneumonia,  and, 
second,  in  the  so-called  Schott  method  of  the  treatment  of  valvula; 
heart  disease.  In  the  latter  of  these  the  effect  upon  the  mechanism  ia 
the  same  simple  one  as  before — the  application  of  cold  or  cool  water 
to  the  body  surface,  this,  however,  being  rendered  more  stimulating, 
first,  by  the  addition  of  considerable  quantities  of  salts,  chiefly  such 
as  will  be  found  in  sea  water ;  and,  second,  in  the  later  stages  by  the 
introduction  of  that  unrivalled  stimulant  to  involuntary  unstriped 
muscle  fibre — carbonic  acid.  In  this  last  case  we  have  obviously  the 
temperature  factor  completely  eliminated,  and  the  nervous  system  as 
such  almost  equally  so,  for  these  patients  are  usually  in  a  fairly  good 

*  "  Animal  Physiology." 


10          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

state  of  equilibrium  with  the  one  defect  of  the  inadequacy  of  their 
great  heart  pump.  So  marked  is  the  effect  of  this  skin  tonic  that  in 
severe  cases  of  dilatation  the  almost  incredible  result  is  attained  of 
causing  the  apex  actually  to  retract  three-quarters  of  an  inch  toward 
its  normal  position  in  a  single  treatment.  Not  only  are  the  pulsations 
of  the  heart  greatly  lowered  in  frequency,  but  they  are  apparently  in- 
creased proportionately  in  power,  so  that  the  work  which  was  previous- 
ly altogether  too  much  for  it  is  performed  with  comparative  ease  and 
comfort.  In  fact,  the  results  obtained  from  this  simple  remedy  sound 
almost  too  good  to  be  true,  and  would  hardly  be  believed  if  the  re- 
peated experience  of  competent  clinicians  did  not  almost  unanimously 
verify  them. 

"  Now,  it  seems  to  me  that  on  no  possible  theory  which  regards  the 
heart  as  the  sole  motive  force  of  the  circulation,  and  the  heart  muscle 
as  the  only  muscle  in  the  vascular  system  possessing  powers  of 
rhythmic,  propulsive  contraction,  can  more  than  the  merest  fraction  of 
any  of  these  three  great  classes  of  results  be  explained.  But,  suppose 
we  recognize  the  power,  already  suggested,  of  constant  rhythmic  con- 
traction upon  the  part  of  the  muscular  tissue  wherever  found  in  the 
vascular  system — grant  this,  and  it  seems  to  us  that  the  problem  in 
all  three  cases  is  well-nigh  solved.  The  voluminousness  and  func- 
tional importance  of  the  great  mesh  of  blood-vessels  contained  in  the 
skin  and  subcutaneous  tissue,  its  importance  as  a  heat-regulating  and 
excretory  factor,  have  been  insisted  upon  by  all  physiologists ;  and  if, 
in  addition,  we  have  the  right  to  regard  this  enormous  mesh,  capable 
of  containing  nearly  thirty  per  cent,  of  the  entire  blood  of  the  body, 
as  endowed  with  the  power  of  independent  contraction  in  its  muscular 
walls,  we  have  at  once  a  factor  in  the  circulation  which  could  be  de- 
pended upon  for  the  production  of  some  most  striking  results.  In 
fact,  we  venture  to  claim  that  in  the  blood-vessels  of  the  skin  and  un- 
derlying tissues  we  have  in  the  higher  vertebrates,  just  as  found 
everywhere  in  the  lower  forms  of  life,  a  great  'skin  heart,'  which 
plays  an  important  part  in  the  circulation,  not  only  in  health  but  also 
in  disease.  For  instance,  in  the  effect  of  the  Brand  baths,  the  fact 
that  the  local  stimulant  effect  upon  the  vessels  of  the  skin  is  promptly 
followed  by  a  rapid  reactionary  dilatation  is  as  familiar  as  the  alpha- 
bet; but  just  why  this  reaction  should  so  immensely  improve  the 
quality  of  the  heart's  action  and  relieve  the  toxic  condition  of  the 
whole  nervous  system  is  as  yet  hardly  accurately  explained.  It  was 
usually  accounted  for  simply  on  the  ground  that  it  relieves  the  work 
of  the  heart  by  dilating  the  skin  vessels  and  diminishing  peripheral 
resistance. 

"  But  Winternitz  observes,  what  a  glance  at  the  flushed  skin  of  the 


THE   PHYSIOLOGICAL    EFFECTS   OF   WATER.  11 

fever  patient  would  immediately  suggest  to  the  eye,  that  we  have  al- 
ready a  distended  condition  of  the  peripheral  blood  channels  due  to 
paralysis  of  the  vessel  walls,  and  insists,  in  flat  contradiction  to  the 
other  explanation,  that  the  heart's  action  is  improved  by  the  restora- 
tion of  resistance  in  the  peripheral  circulation.  But  let  us  once  admit 
that  the  fundamental  element  in  this  so-called  '  improvement  of  the 
tone '  in  the  superficial  vessels,  the  appearance  of  which  all  investi- 
gators agree  upon,  is  really  an  active  and  not  a  passive  one,  a  local 
rather  than  a  reflex  change ;  in  other  words,  that  the  normal  condi- 
tion of  the  muscles  in  the  walls  of  the  arterioles  and  the  amoeboid  en- 
dothelium  of  the  capillaries,  as  elsewhere,  is  not  one  of  rest,  either  in 
contraction  or  in  dilatation,  but  of  constant  rhythmic  activity,  and  that 
the  restoring  of  this  active  contractility  in  the  vast  mesh  of  vessels  in 
the  skin,  by  the  contact  of  cold  water  and  by  friction,  is  the  essential 
element  in  the  improvement  of  the  circulation.  The  heart  itself  is 
nothing  but  a  special  local  aggregation  of  these  same  muscular  fibres, 
and,  like  them,  its  action  is  intrinsic  and  merely  regulated  by  the  so- 
called  cardiac  nerves ;  and,  when  we  recall  that  the  great  contractile 
mesh  of  the  cutaneous  vessels  is  capable  of  containing  over  thirty  per 
cent,  of  the  entire  blood  of  the  body,  and  that  the  whole  of  this  sur- 
face is  affected  by  the  cold  bath,  it  hardly  seems  impossible  that  the 
stimulation  of  this  great  diffuse  '  skin  heart '  may  be  a  factor  of  the 
greatest  importance  in  improving  the  entire  circulation. 

"  Xow  let  us  see  of  what  assistance  this  hypothesis  would  be  in  ex- 
plaining the  remarkable  effects  of  the  Schott-Nauheim  treatment. 
Upon  what  would  these  cool  baths,  with  a  high  percentage  of  saline 
constituents  in  them,  rendered  still  more  stimulating  by  the  addition  of 
carbon  dioxide,  and  prevented  from  depressing  or  chilling  the  system 
by  subsequent  passive  movements  and  gentle  friction,  be  most  likely  to 
act?  Obviously,  upon  the  great  skin  mesh.  And,  when  we  remember 
that  we  are  practically  plunging  the  cells  of  this  entire  heart  into  their 
old  ancestral  medium  of  sea-water,  and  adding  to  it  the  one  remedy 
which  most  powerfully  increases  peristaltic  action  on  the  part  of  any 
of  the  unstriped  muscles  of  the  body,  as  seen  in  animals  poisoned  by 
it  (carbon  dioxide),  could  we  imagine  anything  which  would  be  much 
more  likely  to  stimulate  to  its  highest  degree  of  vigorous  contraction, 
and  restore  to  its  molluscan  and  crustacean  long-swinging,  tireless 
rhythm,  the  great  skin  heart? 

"  The  first  shock  of  the  cold  stimulates  the  whole  mesh  to  contract 
forcibly  and  drive  on  the  stagnant  blood,  not  merely  through  the 
arterioles,  but,  by  acting  upon  the  unquestionably  contractile  epithelial 
capillary  wall,  through  the  capillary  system;  by  a  similar  stimulation 
of  their  linings  and  walls  through  the  lymphatic  and  venous  systems 


12          THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

the  lymph  which  has  become  poison  instead  of  food  to  the  tissues. 
This  when  thrown  into  the  right  side  of  the  heart  provides  the  great- 
est stimulus  for  contraction  of  the  ventricular  muscle — namely,  active 
dilatation  with  an  abundance  of  blood.  The  lungs  do  their  part  in 
purifying,  and  return  it  to  the  left  side  of  the  heart,  from  which  it  is 
driven  in  abundant  flow  through  the  kidneys,  thus  accounting  for  the 
marked  increase  of  urinary  secretion  after  this  treatment.  But  if  the 
action  ended  here,  we  should  be  only  a  little  better  off  than  before,  for 
upon  the  principle  usually  accepted  the  superficial  blood-vessels,  hav- 
ing contracted,  would  remain  for  a  considerable  length  of  time  in  the 
same  condition,  and  the  heart  would  simply  have  to  overcome  on  the 
arterial  side  precisely  the  same  amount  of  force  which  had  been  added 
to  it  upon  the  venous.  Suppose,  however,  that  the  contraction  has 
been  a  rhythmic  one,  and  that  the  vessels  have  dilated  in  readiness  for 
this  increased  supply  of  purer  blood.  At  the  moment  they  have  re- 
ceived it  they  again  promptly,  no  matter  how  slowly,  contract  and 
drive  it  on  again  into  the  great  veins  (and  that  this  rhythmical  con- 
traction, as  evidenced  by  a  healthy  flush  of  the  skin,  is  steadily  in- 
creased by  the  continued  restoration  of  ancestral  conditions,  the  vigor- 
ous sea  bath  which  the  vessels  are  receiving,  is  evident),  and  it  seems 
to  me  that  we  really  have  a  new  force  added  to  the  circulation,  some- 
thing like  an  adequate  explanation  of  how  the  weak  and  distended  ven- 
tricle can  succeed  in  retracting  its  apex  half  or  three-quarters  of  an 
inch  toward  the  median  line  during  a  single  session. 

"  We  would  again  insist  upon  the  fact  that  neither  in  typhoid  nor  in 
cardiac  inadequacy  can  these  effects,  or  anything  like  them,  be  pro- 
duced by  cold  alone  (for  that  has  been  thoroughly  tried  in  both  cases), 
by  the  temporary  application  of  water  alone,  of  whatever  temperature, 
or  by  either  dry  saline  or  gaseous  or  mechanical  irritants.  It  is  abso- 
lutely necessary  that  not  merely  cold,  but  cold  u-ater,  should  be  used ; 
that  the  surface  should  be  literally  rubbed  with  this  for  a  considerable 
length  of  time ;  that  the  activity  of  this  should  be  markedly  increased 
by  the  addition  of  the  sea  salts,  and  still  further  by  carbonic  acid,  such 
as  would  result  from  abundant  processes  of  oxidation  in  the  water.  In 
fact,  fanciful  perhaps  as  the  suggestion  may  seem,  it  is  by  a  precise 
and  accurate  imitation  of  our  most  ancient  ancestral  surroundings,  in 
cool  sea  water  of  high  degree  of  salinity  and  a  considerable  percentage 
of  carbon  dioxide — in  short,  precisely  the  condition  which  we  find  in 
the  shallow,  sun-warmed  lagoons  in  which  life  probably  originated — 
that  we  reach  the  maximum  of  curative  effect. 

"  Now  let  us  see  for  a  moment  what  basis  of  probability  exists  for 
the  presence  of  this  factor  in  the  present  state  of  our  physiological 
knowledge.  Although,  as  I  confessed  at  the  beginning,  little  more 


THE   PHYSIOLOGICAL   EFFECTS   OF   WATER.  13 

than  suggestions  of  its  possibility  can  be  given,  yet  there  are  several 
of  these.  In  the  first  place,  all  observers  for  the  last  thirty  years  have 
reported,  from  time  to  time,  the  appearance  of  rhythmic  contractions 
in  certain  groups  of  the  vessels  of  the  lower  forms,  not  merely  in 
the  invertebrates,  but  also  in  the  lower  vertebrates,  even  in  mam- 
mals. 

"  The  farther  we  go  down  the  scale,  the  more  frequent  this  becomes. 
In  fact,  in  the  invertebrates  it  may  be  regarded  as  the  rule.  Among 
the  lower  vertebrates  the  vessels  in  the  wing  of  the  bat,  in  the  fin  of 
the  eel,  in  the  fins  of  various  fishes,  and  in  the  foot  web  and  mesentery 
of  the  frog  have  been  seen  repeatedly  to  possess  the  power  of  constant 
though  slow  rhythmic  contraction.  In  many  cases  this  has  been  re- 
ported without  any  apparent  suspicion  of  its  real  nature;  as,  for  in- 
stance, when  the  arterioles  of  the  frog  are  reported  to  seem  to  '  vary 
spontaneously,'  and  when,  as  Curtiss  states,  in  watching  the  capillary 
area  in  a  rabbit's  ear,  '  capillaries  not  noted  before  may  suddenly 
spring  into  view '  and  shortly  after  disappear.  Among  mammals 
almost  every  observer  has  commented  upon,  with  varying  resultant 
opinions,  the  singular  rhythmic  contraction  frequently  observed  in  the 
ear  of  the  rabbit,  and  occasionally  in  the  mesentery  of  the  same  ani- 
mal. Curtiss  also  admits  that  the  capillary  walls  are  evidently 
'  living  cells  and  possibly  contractile. '  Porter  declares  that  there  has 
been  much  discussion  over  the  rhythmic  contractions  present  in  some 
of  the  vascular  areas  of  mammals ;  and  these  are  but  a  few  of  dozens 
of  admissions  of  the  existence  of  such  contractility  (at  least  of  occa- 
sional signs  of  it)  in  the  mammalian  blood-vessels. 

"  Of  course  it  hardly  needs  to  be  said  that  it  is  only  occasionally 
that  the  opportunity  for  observing  this  process  in  the  mammalian 
tissues  can  be  obtained;  and  with  the  single  exception  of  the  ear  of 
the  rabbit,  in  which  every  observer  has  noticed  it,  the  placing  of  the 
tissues  in  a  position  to  admit  of  this  change  being  noted,  if  it  oc- 
curred, would  necessitate  a  very  serious  disturbance  of  the  normal  re- 
lations and  even  of  their  vitality.  It  is,  to  my  mind,  significant,  to 
say  the  least,  that  in  the  only  places  in  the  mammalian  kingdom  in 
which  this  phenomenon  might  readily  be  studied,  with  the  parts  in 
their  normal  condition — the  wings  of  the  bat  and  the  ear  of  the 
rabbit — it  has  been  noted,  and  in  some  cases  quite  extensively  specu- 
lated upon,  by  almost  every  observer.  In  fact,  as  Mills  sums  up  the 
discussion  of  this  phenomenon :  '  Such  facts  lend  some  color  to  the 
view  that  the  return  of  vessels  to  their  previous  size  after  distention 
by  the  cardiac  systole  is  aided  by  the  rhythmical  contractions  of  the 
muscle  cells  in  their  walls.'  *  But  we  must  also  admit  that  nearly 
every  investigator  who  takes  the  trouble  definitely  to  pronounce  upon 
*  "  Animal  Physiology. " 


14          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

this  question  expresses  himself  practically  in  the  words  of  Morrant 
Baker:  '  There  appears  to  be  no  reason  for  supposing  that  the  muscular 
coat  assists  to  more  than  a  very  small  degree  in  propelling  the  onward 
current  of  the  blood. '  * 

"  Finally,  are  there  problems  in  the  physiological  aspects  of  the  cir- 
culation which  remain  conspicuously  unsolved,  and  in  which  this 
factor  might  play  a  part?  There  are  three  at  least.  One  of  them  is 
the  much  disputed  question  of  the  dicrotic  wave  in  the  pulse,  which 
has  usually  been  explained  as  a  reaction  wave  upon  the  part  of  the 
elastic  coat  of  the  vessels,  as  an  oscillation  reflected  from  the  periphery, 
as  a  percussion  wave  from  the  closing  of  the  aortic  valve,  and  upon  a 
variety  of  other  grounds.  Upon  closer  examination,  this  wave  is  usu- 
ally found  in  reality  to  consist  of  a  low  predicrotic  and  a  higher 
dicrotic  curve ;  and  we  cannot  resist  the  suggestion  that  we  have  here 
precisely  the  condition  which  would  be  accounted  for  by  supposing 
that  the  first  step  in  the  return  of  the  blood-vessel  to  its  normal 
calibre  was  carried  out  mechanically  by  the  elastic  tissue  in  its  walls, 
producing  the  predicrotic  oscillation,  while  its  return  was  completed 
by  the  active  muscular  contraction  of  the  muscular  coat,  producing  the 
dicrotic  wave  proper.  Moreover,  this  condition  of  affairs  is  exagger- 
ated and  retarded  by  the  lowered  arterial  tone;  by  which  is  meant  a 
relaxed  condition  of  the  muscular  coat,  and  consequently  a  free  and 
complete  distention,  followed  by  a  slow  contraction  of  wider  range, 
corresponding  to  the  degree  of  distention.  In  conditions  which  in- 
crease the  arterial  tone,  in  which  the  distention  from  yielding  is  slight, 
and  the  reaction  so  prompt  as  practically  to  coincide  with  the  recoil  of 
the  elastic  tissue,  not  only  are  the  two  waves  merged  in  one,  but  their 
beginning  is  so  nearly  synchronous  with  the  cessation  of  cardiac  dis- 
tention that  the  downward  curve  is  practically  uninterrupted,  and  the 
dicrotic  wave  almost  disappears  in  high  arterial  tension. 

"  And,  last  of  all,  there  are  certain  reactions  in  the  wonderfully 
complex  and  interesting  problem  of  the  maintenance  of  the  blood- 
pressure  which  still  lack  any  satisfactory  explanation  upon  the  usualty 
accepted  hypothesis  of  the  passive  relation  of  the  arterial  walls;  for 
instance,  the  familiar  increase  of  arterial  pressure  where  an  increased 
amount  of  blood  is  being  driven  through  a  part,  precisely  the  reversal 
of  what  would  be  expected  by  one,  on  a-priori  grounds,  from  the 
action  of  the  vessels  were  they  mere  passive  conducting  tubes.  This 
has  usually  been  lamely  explained  by  calling  into  play  that  mythical 
power  of  the  long-suffering  heart  of  increasing  the  work  done  by  it  in 
direct  proportion  to  the  resistance  offered  to  it ;  which,  if  true  (except 

*Kirkes'  "Physiology,"  p.  207. 


THE   PHYSIOLOGICAL   EFFECTS   OF   WATEB.  15 

for  a  very  limited  period),  would  place  it  upon  a  perfectly  abnormal 
pinnacle  of  biologic  virtue.  Suppose,  however,  that  this  increase  of 
the  arterial  pressure  is  due  to  the  active  propulsive  pressure  which  the 
muscle  wall  is  exerting  upon  the  blood,  and  that  its  contractions  occur 
at  the  same  rate  with  those  of  the  heart,  but  in  the  intervals  between 
them,  and  we  can  at  once  see  how  the  blood  pressure  may  be  distinctly 
raised  and  yet  the  work  of  the  heart  not  only  not  increased  but  dis- 
tinctly diminished  thereby. 

"  In  fine,  we  would  venture  to  submit  the  conclusions,  simply  as  a 
basis  for  further  investigation  and  discussion : 

"  First,  that  the  existence  of  active  contractility  upon  the  part  of 
the  muscular  wall  of  the  arteries  and  arterioles,  and  in  less  degree  of 
the  veins  and  lymphatics,  and  of  the  capillary  epithelium,  is  some- 
thing which  we  have  the  strongest  reason  to  expect  upon  ancestral 
grounds  in  even  the  highest  mammals. 

"  Second,  that  the  beneficial  effects  of  cold  water  upon  the  circula- 
tion, particularly  of  a  high  degree  of  salinity  and  accompanied  by 
friction,  (first)  in  health,  (second)  in  the  Brand  method  in  typhoid  fever, 
and  (third)  in  the  Schott-Nauheim  method  in  cardiac  disease,  are  ade- 
quately to  be  explained  only  upon  the  ground  of  the  persistence  of 
such  a  power  in  our  mammalian  skin  heart. 

"  Third,  that  the  occurrence  of  this  sort  of  contraction  is  almost  uni- 
form in  invertebrates,  and  has  been  observed  in  the  vascular  area  of 
many  of  the  lower  vertebrates — frogs  and  fishes;  and  in  those  posi- 
tions in  which  it  could  be  readily  seen  under  normal  conditions  in  the 
higher  vertebrates — the  wing  of  the  bat  and  the  ear  of  the  rabbit; 
so  that  we  have  abundant  grounds  for  the  possibility  and  some  even 
for  the  probability  of  its  occurrence  in  our  own  species. 

"  Fourth,  that  in  the  behavior  of  the  vessels  in  health,  as  noted  by 
physiologic  investigators,  there  are  again  conditions  which  are  ad- 
mittedly unexplained,  and  yet  which  may  be  accounted  for  on  this 
supposition — the  rhythmic  pulsation  of  the  vessels  in  the  rabbit's  ear, 
the  restoration  of  normal  tone  on  the  part  of  the  vessels  of  any  area 
after  recovery  from  section  of  the  vasomotor  nerves,  the  persistence 
of  contraction  in  the  ventricle  in  lower  vertebrates  and  auricle  in  all 
forms  after  the  section  of  all  the  cardiac  nerves,  the  phenomena  of 
the  dicrotic  wave,  and  the  anomaly  of  an  increase  in  the  rapidity  of 
the  circulation  and  amount  of  blood  in  a  given  part  coinciding  with  the 
marked  increase  of  the  arterial  resistance." 

Hasebrook  *  concludes  an  able  article  on  gymnastic  treatment  of 
cardiac  diseases  by  affirming  the  independence  of  the  peripheral  cir- 
culation. He  says  that  diastolic  and  systolic  activity  expresses  it- 
*D.  Arch.  f.  klin.  Med.,  Bd.  Ixxvii. 


16          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

self  in  the  capillaries  of  the  tissues  as  suction,  in  the  arterial  field 
more  as  propulsive  action. 

The  author  has  reproduced  Dr.  Hutchinson's  "  skin-heart "  theory, 
because  it  confirms  his  own  views  on  the  subject,  reached  independ- 
ently on  clinical  grounds,  and  when  combined  with  the  action  of  the 
skin  muscles  upon  the  cutaneous  capillary  area  which  he  has  endeavored 
to  emphasize  it  explains  a  very  plausible  element  in  the  theory  of  re- 
action, which  has  long  been  a  subject  of  dissenting  views  among 
hydrotherapists  (see  article  Reaction). 

Veins. — The  share  borne  by  the  cutaneous  veins,  i.e.,  the  super- 
ficial veins  which  are  so  abundant  and  of  large  calibre  in  the  extremi- 
ties, in  the  rationale  of  hydrotherapy  has  not  obtained  the  considera- 
tion to  which  it  is  entitled.  The  author  has  long  suspected  that 
enormous  masses  of  venous  blood  must  be  displaced  by  the  same  con- 
traction which  cold  procedures  produce  in  the  superficial  smaller 
vessels,  because  blood  contents  of  these  veins  are  so  easily  changed  by 
position,  for  instance.  Having  cognizance  of  no  anatomical  or  physi- 
ological studies  of  recent  date,  he  has  hitherto  omitted  mention  of  the 
venous  circulation  in  this  chapter,  rather  than  indulge  in  theoretical 
discussion  or  unsupported  empirical  data.  In  the  Journal  of  the 
American  Medical  Association)  October  20th,  190G,  Sewell  writes  (p. 
1283)  (the  italics  are  mine) : 

"  The  relatively  slight  musculature  of  the  veins  has  led  to  underesti- 
mation of  their  contractile  function.  In  comparing  the  veins  with  the 
arteries  as  contractile  mechanisms  it  is  only  fair  to  consider  the  ratio 
of  muscle  mass  in  a  given  section  of  vein  to  the  mean  blood  pressure 
it  must  react  against,  with  the  similar  ratio  in  a  corresponding  artery. 
The  subject  of  vein  physiology  seems  to  have  received  very  limited  atten- 
tion. Bancroft  *  studied  the  veins  in  the  hind  limbs  of  cats  and  rab- 
bits. No  marked  decrease  in  the  calibre  of  the  veins  was  produced  by 
clamping  the  aorta,  the  vein  becoming  simply  flattened  and  flabby. 
But  stimulation  of  the  sciatic  nerve  caused  marked  contraction,  which 
was  irregularly  localized.  The  effect  of  the  stimulation  was  much 
influenced  by  the  conditions  of  exposure  of  the  vein,  and  the  vasomotor 
apparatus  was  very  subject  to  fatigue. 

A  study  of  the  human  veins  demonstrates:  1.  That  the  vein  ///•/// 
be  emptied  either  passively  by  failure  of  inflow  or  actively  by  its  own 
contraction.  2.  That  in  the  relaxed  and  partially  filled  vein,  at  least 
when  held  horizontally,  the  blood  may  flow  freely  past  a  valve  in 
either  direction.  3.  That  the  closure  of  a  vein  valve  is  usually,  if 
not  always,  produced  by  active  vein  contraction,  primarily  of  the 

v      *Huber,  Bohm,  Davidoff:  "Text-Book  of  Histology,"  1900. 


THE   PHYSIOLOGICAL   EFFECTS   OF   WATER.  17 

vein  segment  peripheral  to  the  valve,  and  probably  secondarily  by 
that  central  to  it.  It  seems  reasonable  to  suppose  that  abnormal  dila- 
tation (varicosity)  of  veins  depends  on  failure  of  vein  contractility  to 
make  the  valves  sufficient.  4.  Vein  contraction  can  be  sharply  local- 
ized. The  normal  master  stimulus  of  venous  contractility  is  cold,  es- 
pecially ivhen  associated  with  light  friction.  6.  The  contractile  mani- 
festations of  the  veins  vary  greatly,  probably  from  introduction  of  a 
fatigue  element. 

"  In  the  superficial  veins  and  those  of  the  lower  limbs  the  muscu- ( 
lature  is  said  to  be  relatively  well  developed.     'Flattened  and  circu- 
larly arranged  muscle  cells  are  met  with  at  the  inner  surface  of  many 
of  the  larger  valves.' 

"  In  persons  in  whose  arms  the  superficial  veins  are  prominent,  the 
veins  contract  and  the  valves  become  more  or  less  visible  on  exposure 
of  the  arm  to  cool  air.  If  now  the  arm  is  slightly  brushed  from  wrist 
to  shoulder  by  a  single  pass  of  the  other  hand,  the  veins  thus  irritated 
may  become  completely  invisible,  or  still  appear  as  white  cords,  though 
their  course  is  plotted  by  the  valves,  each  of  which  is  held  shut  by  a 
droplet  of  blood  kept  -in  place  by  the  contracted  vein  central  to  it. 
The  contractile  power  of  the  vein  may  still  keep  the  droplet  of  blood 
in  place  over  the  valve  for  a  time  when  it  is  opposed  by  the  influence 
of  gravity  through  elevating  the  arm.  When  a  vein  is  dilated,  me- 
chanical irritation  of  a  limited  segment  sometimes  causes  a  tonic  local 
contraction  of  that  part.  When  the  blood  is  smartly  brushed  out  of  a 
full  vein  up  to  a  given  valve  and  then  prevented  from  re-entering 
below,  the  emptied  segment  of  vein  seems  to  be  actively  contracted 
and  sharply  marked  off  from  the  full  vein  terminated  by  the  closed 
valve  beyond. 

"  When  the  hand  is  soaked  in  cold  water  for  a  minute,  the  veins 
contract  and  become  nearly  or  quite  invisible.  But  at  the  same  time 
the  skin  of  the  hand  becomes  very  red.  There  is  no  accompanying 
change  of  arterial  pressure  in  the  arm.  The  congestion  of  the  hand  is 
evidently  produced  by  capillary  engorgement  due  to  increased  resist- 
ance offered  to  the  flow  of  blood  by  the  contracted  veins.  The  venous 
pressure  falls  somewhat  after  this  procedure,  but  is  not  nearly  so  low 
as  when  measured  in  a  vein  of  the  same  degree  of  distentioii  when  the 
skin  is  pale.  That  is,  in  the  first  case  the  ratio  of  inflow  to  resistance 
in  the  veins  is  much  greater  than  in  the  second.  In  other  words, 
when  a  vein  becomes  smaller  by  active  contraction  of  its  walls,  the 
pressure  within  it  tends  to  rise ;  when  the  diminution  of  its  size  de- 
pends on  diminished  arterial  inflow,  the  venous  pressure  always  falls. 

"The  localized  contraction  of  veins  is  well  illustrated  after  immer- 
sion of  the  hand  and  half  the  forearm  in  cold  water.  For  minutes 


18          THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

after  the  removal  of  the  member  the  veins  remain  small  or  invisible 
over  the  area  which  had  been  chilled,  while  just  above  it  the  veins  of 
the  arm,  fed  from  the  deeper  tissues,  may  be  fully  dilated ;  the  result 
is  especially  striking  if  a  slightly  constricting  band  is  laid  round  the 
upper  arm." 

A  correct  appreciation  and  understanding  of  the  anatomy  and 
physiology  of  the  cutaneous  circulation  are  absolutely  demanded  for 
the  comprehension  of  the  varied  and  sometimes  apparently  inconsist- 
ent results  obtained  from  the  application  of  water  in  disease. 

Nerves, — The  nerve  supply  of  the  skin  consists  of  medullary  and 
non-medullated  fibres.  The  sensory  branches  from  the  cerebral  and 
spinal  nerves  (mixed  with  vasomotor  nerves)  and  the  motor  nerves  of  the 
cutaneous  muscular  structure  under  the  skin  form,  according  to  Unna, 
plexuses  in  much  coarser  bundles  and  more  distinct  arrangement  than 
those  seen  in  the  blood  vessels.  In  the  subcutaneous  tissues  they 
present  a  more  extensive  horizontal  course ;  they  repeatedly  break  into 
thin  branches  before  they  finally  penetrate  the  cutis  vera  in  company 
with  the  vessels.  At  some  points  in  the  skin  they  give  off  within  the 
subcutaneous  tissue  branches  to  the  Pacinian  corpuscles.  After  pene- 
trating the  cutis,  the  nerves  again  bend  at  the  lower  border  of  the 
papillary  bodies,  and  assume  a  horizontal  position  in  order  to  form  a 
real  nerve  plexus  just  beneath  the  epidermis.  Krause  claims  the  pres- 
ence of  very  fine  ganglionic  cells  in  those  nerve  fibres  which  still  re- 
tain a  medulla.  The  uppermost  branches  are  very  short,  and  losing 
their  medulla  terminate  just  under  the  epidermis  in  fine  fibrillae,  which 
are  distributed  in  great  abundance,  and  furnish  some  branches  to  the 
endothelia  of  the  papillary  vessels.  Others  are  found  free  in  the  con- 
nective tissue  with  fine,  button-shaped  ends.  Another  portion  of  these 
nerves  which  still  contain  a  medullary  centre  rises  into  the  papillae 
in  the  direction  of  Meissner's  bodies,  which,  as  is  well  known,  are 
abundantly  distributed  throughout  the  entire  skin. 

The  nerve  supply  of  the  epidermis  is  very  interesting.  According 
to  Unna,  non-medullary  branchlets  of  the  subepidermal  network  arise 
perpendicularly  between  cylindrical  basal  cells,  and  give  off  fine 
branches  in  manifold  netlike  divisions  as  far  as  the  horny  layer. 
They  bore  through  the  plasma  prickle  cells,  and  arrange  themselves  in 
fine,  button-like  ends.  The  typical  nerve  ending  in  the  epidermis  is, 
therefore,  in  pairs,  and  intercellular. 

The  hair  follicles  and  sebaceous  gland  tubules  also  receive  nerve 
fibres  from  branches  which  lie  in  close  apposition  to  the  lower  layer 
of  the  epidermis. 

All  sensory  nerves  end,  according  to  Krause  and  Unna,  in  non- 
medullary  fibres,  which  terminate  in  small,  button-like  enlargements, 


THE   PHYSIOLOGICAL   EFFECTS   OF   WATER.  19 

most  abundantly  found  in  the  cells  of  the  epidermis,  as  far  as  the 
horny  border.  These  afferent  nerves  conduct  thermic  impression,  to 
their  centres. 

Reflex  Areas. — Physiologists  have  studied  the  connection  between 
certain  areas  of  the  skin  and  the  spinal  ganglionic  centres.  The  more 
or  less  positive  data  thus  obtained  are  of  immense  import  to  the 
hydrotherapeutist. 

Between  the  scapulae  the  cutaneous  nerves  represent  the  scapular 
reflex  which  is  in  direct  functional  connection  with  the  first,  second, 
and  third  dorsal  ganglia.  The  cutaneous  nerves  ramifying  near  the 
edges  of  the  recti  muscles  constitute  the  abdominal  reflex  area  which 
is  connected  with  the  eighth,  ninth,  tenth,  eleventh,  and  twelfth  dorsal 
ganglia.  The  cutaneous  covering  of  the  lower  part  of  the  chest  on 
each  side  represents  the  epigastric  reflex  area,  which  is  related  to  the 
fifth,  sixth,  and  seventh  dorsal  ganglia.  The  skin  covering  the  nates 
forms  the  gluteal  reflex  area,  which  is  connected  with  the  fourth  and 
fifth  lumbar  ganglia;  and  the  inner  and  upper  surface  of  the  thigh  is 
the  cremasteric  reflex  area,  which  is  related  to  the  fourth  and  fifth 
lumbar  ganglia. 

In  an  able  essay  on  the  "Nerves  of  the  Capillaries,"  Carl  Sihler* 
turnishes  a  study  of  this  subject,  concluding  that  "  the  nerves  supply- 
ing the  capillaries  connect  also  with  sensory  nerves  and  with  nerves 
surrounding  the  larger  blood-vessels,  both  arteries  and  veins. 
i  "  The  branches  of  the  chorda  tympani  in  the  submaxillary  gland 
do  not  pass  to  the  gland  cells,  but  they  terminate  on  the  capillaries. 

"  In  the  muscular  and  glandular  tissues — and  perhaps  throughout 
the  body — there  is  a  vast  peripheral  nervous  plexus  belonging  to  the 
capillary  blood-vessels.  These  nerves  of  the  capillaries,  which  may 
perhaps  be  regarded  as  nutritive  nerves,  regulate  the  production  and 
transudation  of  lymph,  and  are  concerned  in  the  mechanism  of  gland- 
ular secretion.  They  may  be  called  into  activity  both  by  peripheral 
influences  and  by  impulses  received  from  the  central  nervous  system 
and  the  sympathetic  ganglia.  They  may  influence,  through  their  con- 
nections with  the  vasomotor  nerves  on  the  arteries  and  veins,  the  blood 
supply  to  a  part." 

The  nerve  endings  in  the  skin  here  described  furnish  a,  clew  to  that 
remarkable  sensitiveness  of  the  epidermic  layer  which  opens  to  hydro- 
therapy  a  free  gateway  to  the  central  nervous  system,  and  especially  to 
the  sympathetic,  which  controls  most  of  the  organic  functions. 

Considering  this  anatomical  and  physiological  fact  in  connection 
•with  the  equally  well-established  truth  that  the  ten  thousand  square 
feet  of  capillaries  in  the  skin  are  in  direct  connection  with  the  central 

*The  Journal  of  Experimental  Medicine,  vol.  i.,  No.  5,  1901. 


20          THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

circulatory  system,  it  may  be  claimed  with  absolute  candor  that  he 
who  rightly  appreciates  the  principles  and  practice  of  hydrotherapy 
holds  the  key  to  the  solution  of  many  pathologic  and  therapeutic  prob- 
lems, which  have  hitherto  baffled  the  physician. 

Temperature  of  the  Normal  Skin. — Despite  the  fact  that  all  hydri- 
atric  procedures  are  external,  and  that  their  effects  depend  almost  al- 
together upon  differences  between  the  temperature  of  the  water  ap- 
plied and  that  of  the  skin,  the  temperature  of  the  latter  is  rarely  if 
ever  referred  to  in  descriptions  of  its  physiology  nor  in  the  rationale 
of  the  various  procedures.  In  a  febrile  chronic  disease,  especially,  it 
is  of  immense  importance  to  bear  in  mind  that  the  normal  skin  tem- 
perature averages  from  six  to  eight  degrees  lower  than  the  internal 
temperature.  The  author  regards  92°  F,  as  the  average  a  febrile  skin  tem- 
perature. Various  parts  of  the  body  present  certain  variations,  which 
in  practice  are  utilized,  as  will  be  shown.  It  is  a  matter  of  common 
observation  that  the  lower  extremities  are  easily  cooled,  and  for  this 
reason  cold  applications  are  rarely  made  to  these  parts,  hot  applica- 
tions quite  often.  The  abdomen  is  the  warmest  part  of  the  unex- 
posed  body  in  the  normal  state,  the  forehead  the  warmest  exposed 
part. 

In  this  work  the  prevalent  idea  that  water  below  the  temperature 
of  the  BODY  is  cool  or  cold  water  has  been  avoided,  and  the  more  cor- 
rect view  that  water  below  the  temperature  of  the  SKIN  is  cool  or  cold, 
and  water  above  the  temperature  of  the  SKIX  is  warm  or  hot,  is  insisted 
upon.  _  _ ~  , 


CHAPTER  II. 

FUNCTIONS  OF  THE  SKIN. 

IN  connection  with  liydrotherapy  the  functions  of  the  skin  may  be 
considered  chiefly  in  three  aspects:  first,  as  an  organ  of  sense;  second, 
as  an  organ  of  excretion;  third,  as  an  organ  of  heat  regulation. 

First,  as  an  Organ  of  Sensation. — Roehrig  has  well  epitomized  the 
importance  of  the  skin  as  an  organ  of  sense  by  the  statement  that, 
next  to  sight,  the  sense  of  touch  is  the  most  important  of  all  the 
senses.  Through  this  sense  the  human  organism  is  made  conscious  of 
its  contact  with  the  outer  world.  The  anatomical  distribution  of  the 
nerves  throughout  the  skin  and  their  connection  with  the  central  ner- 
vous system  are  so  perfect  and  complete  that  not  the  finest  pin  point 
may  penetrate  its  uppermost  layer  without  calling  into  action  all  those 
agencies  by  which  the  human  organism  protects  itself  against  threat- 
ening dangers  or  deleterious  influences.  The  cutaneous  nerve  endings 
stand  guard,  as  it  were,  over  most  of  the  functions  of  the  human  body. 
They  are  constantly  exposed  to  irritation  by  heat  and  cold,  which  they 
convey  to  the  vasomotor,  respiratory,  and  cardiac  centres,  and  to  the 
muscles,  in  order  to  arouse  in  them  by  reflex  action  such  a  degree  of 
inuervation  as  may  be  required  to  ward  off  any  damaging  influence 
that  may  approach  from  without.  The  nerve  endings  which  fulfil  this 
important  function  are  the  tactile  corpuscles,  and  Paciuian  bodies,  and 
club-shaped  terminals  which  compose  the  sense  of  touch.  The  latter 
is  composed,  according  to  Goldscheider,*  of  a  large  number  of  specific 
sensations,  each  of  which  is  brought  about  by  separate  nerves.  Gold- 
scheider has  sought  for  the  terminals  of  these  nerves  and  has  established 
their  separate  positions  and  specific  functions.  There  are  points  for 
cold  and  heat,  which  may  be  discovered  by  touching  them  with  small 
hair  or  metal  pencils  moistened  with  ether.  These  points  are  arranged 
in  chains  and  lines,  which  often  radiate  from  a  single  point.  It  is  very 
remarkable  that  these  radiating  points  are  in  lines  common  for  both  cold 
and  heat.  Nevertheless  the  radiations  and  chains  for  cold  do  not  unite 
with  those  for  heat.  The  latter  are  smaller  in  number.  The  sense  of 
cold,  when  aroused  by  irritating  the  cold  points,  is  lightning-like.  The 
sense  of  heat,  when  aroused  by  irritation  of  its  points,  on  the  contrary,  de- 

*Archiv  fur  Physiologic,  1885. 


22          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY, 

velops  more  scowly.  The  temperature  points  may  be  excited  mechani- 
cally and  electrically.  Indeed,  we  may  discover  their  action  very 
plainly  by  touching  a  "cold  point"  with  a  heated  needle.  A  mild 
touch  is  not  noticed  at  these  points,  but  even  the  strongest  touch  does 
not  produce  pain  in  them.  Irritation  of  the  trunks  of  these  nerves 
for  cold  produces  an  eccentric  sense  of  cold,  the  same  as  when  the 
terminals  are  irritated.  For  this  reason  we  often  find  a  temperature 
sensation  following  strong  pressure  which  happens  to  strike  upon  tem- 
perature nerves. 

Examination  of  the  topography  of  the  temperature  sense  shows  that 
it  depends  upon  the  abundance  of  nerves  in  a  part.  For  instance,  in 
the  palmar  ends  of  the  fingers,  which  are  known  to  have  excellent  sense 
of  touch,  the  number  of  temperature  points  is  small,  and  therefore  the 
sense  of  temperature  is  subordinate.  The  belief  that  the  acuteness  of 
the  temperature  sense  depends  upon  the  tenuity  of  the  epidermis  is 
erroneous,  according  to  Goldscheider. 

Separated  from  the  temperature  points  are  the  pressure  points,  which 
furnish  appreciation  of  touch  and  of  locality.  There  are  no  specific 
points  for  the  sense  of  pain,  although  at  certain  points  even  feeble  irri- 
tation may  produce  a  sense  of  pain.  Frey,  of  Leipzig,  regards  it  as 
probable  that  there  are  specific  end  organs  in  the  skin  for  the  pain 
sense,  although  there  are  no  externally  recognizable  points  for  this 
sense. 

Finally,  there  is  a  system  of  nervous  sensation  spread  through  the 
skin,  not  arranged  in  any  recognizable  type,  which  seems  to  enable  us 
to  "feel  our  skin."  While  the  pressure  nerves  give  information  of 
those  objects  which  touch  us  from  without,  the  nerves  of  sensation  are 
the  carriers  or  conveyers  of  the  so-called  general  sense. 

A.  Herzen  holds  that  experiments  made  on  limbs  that  felt  "  asleep" 
go  to  show  that,  while  these  are  deficient  in  the  sense  of  touch  and  the 
sense  of  cold  is  absent,  the  sense  of  heat  is  completely  preserved,  dif- 
fering in  this  respect  from  Goldscheider' s  views.  Herzen  believes  that 
the  sense  of  cold  is  conveyed  on  separate  tracts,  like  the  sense  of  touch, 
through  the  posterior  fibres  of  the  cord,  while  the  tracts  for  the  sense 
of  heat,  like  those  for  the  sense  of  pain,  pass  through  the  gray  sub- 
stance. This  remarkable  fact  was  confirmed  clinically  in  a  case  of 
myelitis  of  the  posterior  cord  with  complete  tactile  anaesthesia  of  the 
lower  extremities,  and  it  was  also  confirmed  by  experiments  on  animals. 

According  to  Roehrig,  the  actual  efficiency  of  the  touch,  pressure, 
and  temperature  senses  depends  upon  the  integrity  of  the  part  of  the 
skin  containing  terminals  of  the  nerves  of  touch.  When  cold  and  heat 
act  directly  upon  the  nerve  trunks,  there  is  neither  a  temperature  sense 
nor  localization.  At  the  most,  we  may  have  a  sense  of  pain  following 


FUNCTIONS   OF   THE   SKIN.  23 

intense  injury,  this  being  a  common  result  of  varied  impressions.  In 
a  similar  manner  the  ends  of  the  nerves  of  touch  lose  their  distinct 
pressure  and  heat  sense  when  intensely  irritated,  because  their  percep- 
tive capacity  is  blunted  by  the  general  sensation  of  pain.  The  portion 
of  the  skin  thus  affected  loses  for  a  time  the  capacity  of  further  irri- 
tability, because  the  nerve  endings  are  overstrained.  Touch  and  pres- 
sure sensations  may  be  regarded  as  due  to  direct  compression  of  the 
tissue  containing  the  nerve  endings,  and  we  judge  the  extent  of  the 
impression  thus  received  by  the  intensity  or  extent  of  the  pressure  im- 
pact. The  case  of  heat  sense  is  similar,  and  depends  upon  that  prop- 
erty of  heat  which  produces  an  expansion  or  contraction  of  the  fluid 
contents  in  the  microscopical  organs  of  touch.  Hence  there  is  also 
in  the  sense  of  heat  a  species  of  pressure  effect  upon  the  nerve 
endings. 

Thus  is  explained  the  well-known  observation  that  we  often  ex- 
change impressions  produced  by  touch  and  temperature  irritants.  For 
instance,  we  usually  overestimate  the  weight  of  a  cold  body,  because 
we  cannot  precisely  separate  pressure  and  temperature  sensation,  but 
preserve  both  as  an  intensified  pressure  sense. 

Another  condition  which  is  important  in  the  production  of  temper- 
ature sensation  is  the  blood  supply  of  the  end  organs  of  the  nerves  of 
temperature,  this  being  subject  to  reflex  action.  Cold  produces  a  con- 
traction of  the  cutaneous  vessels,  and  warmth  causes  their  dilatation. 
This  explains  why  electricity  and  certain  chemical  irritants  of  the 
skin,  which  produce  similar  effects  upon  the  cutaneous  circulation,  are 
capable  of  exciting  the  temperature  nerves  and  producing  a  feeling  of 
warmth.  The  difference  between  the  burning  sensation  produced  by 
mustard  plasters  and  by  the  interposition  of  a  galvanic  current  can 
really  not  be  distinguished  from  that  produced  by  contact  with  a  heated 
object. 

Moreover,  pressure  and  warmth  arouse  such  decidedly  different 
sensations  in  the  central  nervous  system  that  it  is  impossible  to  regard 
them  as  modifications  of  the  same  organ  of  sense.  We  are,  therefore, 
forced  to  conclude  that,  just  as  in  the  tongue  there  are  nerves  of  touch 
and  sense  lying  near  each  other,  with  entirely  different  endings,  so  is 
the  skin  the  seat  of  separate  organs  for  producing  perspiration,  heat, 
and  touch. 

There  is  no  doubt  that  the  impressions  from  the  afferent  and 
efferent  nerves  are  conducted  in  the  same  manner  to  and  from  the 
nerve  centers. 

Temperature  sensations  are  divided  into  positive,  or  sensations  of 
heat,  and  negative,  or  sensations  of  cold,  according  to  the  temperature 
of  the  object  being  higher  or  lower  than  that  of  the  skin.  But,  inas- 


24          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

much  as  the  temperature  of  the  skin  is  constantly  subjected  to  fluctu- 
ations, it  is  clear  that  a  sharp  distinction  between  these  conceptions  is 
not  easily  made.  Generally  the  power  to  perceive  cold  and  heat  is 
subject  to  many  fallacies.  For  instance,  our  judgment  depends  upon 
the  size  of  the  portion  of  the  skin  tonching  the  object,  and  conse- 
quently upon  the  number  of  the  nerve  endings  which  come  in  contact 
with  it.  Temperature  impression  is  thus  intensified  by  the  number  of 
nerve  endings  receiving  it.  In  opposition  to  Goldscheider,  Roehrig 
insists  that  much  depends  upon  the  greater  or  lesser  thickness  of  the 
epidermis,  which  is  a  poor  conductor  of  heat. 

Different  portions  of  the  cutaneous  area  present,  according  to 
Goldscheider,  variations  in  sensitiveness.  This  painstaking  author 
has  demonstrated  that  the  median  line  of  the  body  presents  the  acme 
of  sensitiveness  which  diminishes  with  distance,  but  that  it  is  more 
intense  on  the  left  side,  and  that  the  sense  of  cold  is  more  positive 
than  that  of  heat.  It  would  appear  that  just  over  the  spinal  column 
the  sense  of  cold  and  heat  is  more  feeble  than  in  other  parts  of  the 
back,  on  which  it  is  intense.  Hyperaemic  parts  are  well  known  to  be 
more  sensitive  to  temperature  effects.  This  fact  is  utilized,  as  will  be 
noted,  iu  the  technique  of  various  procedures. 

Repetition  of  exposure  to  temperature  inures  the  skin  to  bear 
changes.  This  fact  is  not  only  clinically  demonstrated,  but  has  re- 
ceived laboratory  investigation.  Surig  and  Lode  *  confirmed  Kasa- 
roff's  observation  f  that  after  repeated  cold  baths  dogs  do  not  mani- 
fest the  rectal  temperature  reduction  first  noted.  They  explained 
this  adaptation  to  temperature  impressions  to  a  blunting  of  sensibility 
to  cold  which  improves  the  physical  regulation  of  heat  (as  distin- 
guished from  the  chemical,  which  is  due  to  tissue  changes).  They 
insist  also  that  it  is  not  due  to  a  training  of  the  smooth  muscular 
fibres  of  the  cutaneous  vessels.  AVhile  the  latter  may  be  true,  there 
can  be  no  doubt  that  the  muscular  fibres  of  the  skin  receive  a  training 
by  repeated  brief  exposures  to  cold  that  must  inure  the  capillaries 
contained  in  it  to  cold  and  improve  their  "tone." 

To  sum  up,  we  have  in  the  nerve  apparatus  of  the  skin  facilities 
for  perceiving  pain,  temperature,  and  space,  the  aggregate  of  which 
endows  it  with  all  the  intricate  functions  of  an  organ  of  sensation. 
The  enormous  importance  of  the  skin  as  an  organ  of  sensation  is  exem- 
plified by  the  pathological  conditions  which  accompany  loss  of  reflex 
'sensibility.  In  old  hemiplegiasthe  skin  is  shrivelled  and  dried,  show- 
ing a  lack  of  proper  nutrition ;  in  facial  paralysis  impairment  of  the 
nutrition  is  also  evidenced  by  the  wilted  and  emaciated  condition  of 
the  skin  of  the  face;  in  severe  sciatica,  pallor  and  coolness  of  the 
skin  are  not  infrequent. 

*  Arch.  f.  Hygiene,  39,  1901.  f  Virch.  Archiv,  1882. 


FUNCTIONS   OF   THE   SKIX.  25 

Second,  as  an  Oryan  of  Secretion  and  Excretion. — That  the  skin  is 
important  as  an  organ  of  excretion  has  been  recognized  so  long  ago  a.s 
the  time  of  Galen.  But  the  idea  which  has  until  recent  times  prevailed, 
that  the  skin  excretes  so  many  deleterious  elements  that  the  suppression 
of  the  latter  invariably  and  quickly  becomes  a  lethal  factor,  is  erro- 
neous. The  familiar  example  of  the  boy  who,  being  gilded  to  represent 
an  angel  at  one  of  the  papal  coronations,  died  under  this  manipulation, 
is  no  longer  accepted  as  illustrating  the  danger  of  suppressing  the  excre- 
tory functions  of  the  skin.  Death  by  covering  animals  with  imperme- 
able substances  is  now  known  to  be  due  to  a  disturbance  of  the  heat 
regulation  by  which  the  inner  temperature  is  finally  reduced  below  a  safe 
point.  This  is  proved  by  the  fact  that  when  the  temperature  of  ani- 
mals thus  subjected  to  an  impermeable  covering  is  maintained  by  sur- 
rounding them  with  warm  air  they  do  not  so  readily  succumb.  The 
effect  of  varnishing  the  skin,  when  not  so  counteracted,  is  a  sudden  rise 
of  temperature  with  all  the  symptoms  of  a  febrile  condition,  such  as 
weariness,  rapid  pulse,  and  respiration;  the  latter  gradually  becomes 
slower,  the  temperature  falls,  the  animal  becomes  dull,  albuminuria 
and  convulsions  ensue,  the  exhalation  of  CO5  is  reduced  to  one-seventh 
of  the  normal,  and  the  temperature  falls  to  80 "  F. 

Although  the  suppression  of  the  perspiration  is  not  so  imminently 
dangerous  as  was  formerly  supposed,  the  secretory  function  of  the  skin 
is,  nevertheless,  of  great  importance  in  the  maintenance  of  a  healthy 
condition.  Through  its  extensive  glandular  structure,  an  enormous 
discharge  of  water  is  produced  from  the  cutaneous  surfaces.  Carbonic 
acid  also  is  exhaled  through  the  skin,  as  well  as  urea.  According  to 
Schierbach,*  CO2  is  eliminated  in  moderate  quantities  from  the  skin 
when  the  temperature  ranges  from  29°  to  33°  C.  A  rise  over  33°  pro- 
duces a  sudden  increase  of  CO2,  which  may  be  doubled  when  34°  is 
reached.  Watery  excretion  is  not  abundant  under  33°;  it  increases 
simultaneously  with  the  C00  excretion,  both  being  probably  produced 
by  the  activity  of  the  gland  cells. 

Lombard o  (Giornale  Italiana  delle  Malattie  Venere  e  della  Pelle, 
1907-8)  found  glycogen  constantly  in  the  secreting  epithelium  of  the 
sebaceous  glands,  and  in  the  external  epithelial  layers,  from  the  bulbs 
to  the  insertion  of  the  arrectores  pilorum. 

In  various  diseases  of  the  lungs  and  heart  also,  in  which  other 
physiological  functions  of  these  organs  are  diminished,  the  exhalation  of 
CO.,  by  cutaneous  excretion  is  usually  enhanced.  Witness  the  profuse 
perspiration  attendant  upon  severe  asthma ;  the  walls  of  the  cutaneous 
vessels  are  dilated;  more  water,  aqueous  vapor,  and  carbonic  acid  are 
excreted ;  and  the  dyspnoea  is  somewhat  relieved.  So,  when  the  heart's 
action  is  embarrassed,  the  lumina  of  the  cutaneous  vessels  become 
distended,  affording  some  compensatory  action  to  tide  the  patient  over 
*  Archiv  fur  Anatomie  und  Physiologie,  1893. 


26          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

immediate  danger.  The  clammy  sweat,  characteristic  of  cardiac  in- 
adequacy, is  a  commonly  observed  clinical  phenomenon. 

The  similarity  in  the  anatomical  structure  of  the  skin  and  the  glo- 
meruli  of  the  kidneys,  and  the  chemical  resemblance  of  perspiration  and 
urine,  have  often  been  pointed  out.  Many  clinical  observations  go  to 
show  that  the  skin  is  one  of  the  most  important  aids  to  the  kidneys. 
That  the  perspiration  and  urine  are  excretions,  to  a  certain  extent 
vicarious,  is  proved  by  the  fact  that  their  relation  in  this  respect  is 
generally  enhanced  in  disease.  Thus  is  produced  an  increase  in  the 
perspiration  of  those  constituents  which  the  kidneys  are  incapable  of 
eliminating.  Urea  has  been  found  by  Favre,  Picard,  and  Funke,  in 
the  normal  perspiration  to  the  extent  of  0.1  to  0.2  per  cent.  The  eli- 
mination of  the  most  dangerous  chemical  elements  by  the  skin  is  gen- 
erally enhanced  in  those  diseased  conditions  in  which  the  kidneys  be- 
come inadequate.  Schottein,  who  failed  to  discover  urea  in  the  normal 
perspiration,  observed  it  when  the  kidneys  became  inadequate,  as  in 
the  uraemia  of  cholera.  In  these  cases  he  saw  the  whole  body  covered 
with  a  thin  white  crystalline  layer  of  urea.  Unna  confirms  this  state- 
ment by  observations  made  in  cases  of  uraemia  due  to  suppuration  of 
the  kidneys  and  in  cholera  typhoid,  in  which  these  deposits  could  be 
scraped  off  daily  in  large  quantities. 

Conrad  Brunner*  has  demonstrated  in  a  man  suffering  from  pyaemia, 
in  whose  blood  the  staphylococcus  albus  was  present,  that  perspiration 
induced  by  wet  packs  contained  the  staphylococcus  abundantly  in  six 
or  eight  examinations.  To  verify  this  observation,  Brunner  experi- 
mented upon  two  pigs,  which  were  made  pyaemic  by  injections  of  the 
staphylococcus  aureus.  In  the  sweat  produced  in  these  animals  by 
pilocarpine,  numerous  cultures  of  these  staphylococci  were  found.  In 
a  cat  impregnated  with  bacilli  of  anthrax,  sweat  produced  in  the  foot 
by  faradization  of  the  sciatic  nerve  showed  the  presence  of  these  bacilli. 

Tizzoni  reports  a  case  of  septicaemia  arising  in  the  left  knee,  after 
a  condition  for  which  the  knee  was  excised  and  disinfected  without  re- 
sult on  the  general  infection.  During  the  illness,  to  which  the  patient 
succumbed  after  amputation  of  the  limb,  a  miliary  eruption  appeared 
on  the  skin  which,  upon  being  opened  after  careful  disinfection  with 
sublimate  and  alcohol,  Avas  found  to  contain  a  pure  culture  of  staphy- 
lococcus pyogenes  aureus,  proved  by  culture  on  gelatin  and  agar. 
The  same  micro-organism  was  found  in  the  urine. 

Bernabie  describes  a  case  of  puerperal  peritonitis,  in  which  the 
secretion  from  the  uterus  contained  streptococci.  The  latter  were  also 
found  three  times  in  miliary  vesicles  on  the  skin  and  in  bedsores,  and 
at  points  which  had  been  inflamed  by  subcutaneous  ether  injections. 

Gaertner  also  found,  in  a  case  of  sepsis  after  turning  for  placenta 

*  "Ueber     Ausscheidung     pathogener     Micro-Organismen     durch     den 
Schweiss. "     Berliner  klinisrhe  Wochenschrift,  189J:,  No.  21. 


FUNCTIONS   OF   THE   SKIN.  27 

praevia,  the  staphylococcus  albus  in  the  blood  and  in  the  perspiration, 
together  with  other  diplococci.  He  reports  two  other  cases  of  infec- 
tion in  which  he  found  in  the  perspiration  the  same  staphylococcus 
which  existed  in  the  blood. 

These  well-authenticated  observations  prove  incontestably  the  im- 
portance of  the  skin  as  a  secreting  and  excreting  organ  in  health,  and 
the  vicarious  utility  of  this  function  in  disease. 

It  remains  to  be  shown  later  how  hydrotherapy  may  utilize  its 
enormous  influence  upon  this  function  of  the  skin  in  disease. 

Third,  the  Skin  as  a  Heat  Regulator. — This  is  the  most  important 
function  of  the  skin  when  considered  in  connection  with  hydrotherapy. 
It  depends  to  a  great  extent  upon  the  two  functions  discussed  above. 
To  the  human  organism  the  maintenance  of  the  body  temperature  is  of 
paramount  importance,  and  the  contribution  of  the  skin  to  this  process 
is  indispensable.  It  is  a  trite  physiological  fact  that  the  standard  of 
the  body  temperature  depends  upon  the  maintenance  of  an  equilibrium 
between  heat  production  and  heat  loss.  Without  entering  upon  the 
theoretical  questions  involved,  it  may  be  stated  that  heat  is  produced 
by  the  combustion  of  non-nitrogenized  substances,  chiefly  in  the  mus- 
cles, and  that  heat  is  given  off  by  perspiration  and  radiation  from  the 
cutaneous  surface.  When  heat  loss  exceeds  production,  the  temper- 
ature is  lowered  until  the  processes  of  life  are  interrupted  and  cease. 

The  following  physiological  facts,  trite  though  they  be,  are  of  inter- 
est in  this  connection.  The  temperature  of  the  living  human  body  is 
not  governed  by  physical  laws  alone;  it  is  supplied  with  a  mechanism 
whose  function  it  is  to  protect  the  body  against  serious  heat  loss  by 
calling  forth  certain  conditions  before  dangerous  or  low  temperatures 
are  reached.  When  the  body  is  exposed  to  temperatures  much  below 
its  own,  the  peripheral  vessels  in  the  skin  are  contracted.  Their  lumina 
are  narrowed ;  the  circulation  of  blood  is  gradually  diminished  in  force. 
The  loss  of  heat  from  the  cutaneous  surface  being  governed  by  the 
activity  of  its  circulation,  less  heat  is  now  lost.  Besides,  a  collateral 
hypersemia  ensues  in  the  underlying  parts  which  offers  a  barrier  to  the 
penetration  of  cold.  Inasmuch  as  cold  inhibits  the  action  of  the  vaso- 
motor  centre  which  governs  the  abdominal  splanchnic  nerve,  the  large 
vascular  area  which  is  under  control  of  this  nerve  is  greatly  increased; 
the  cold  blood  is  thus  drawn  into  this  warmer  locality  for  safe  keeping, 
as  it  were.  At  the  same  time  the  muscular  structures  of  the  skin  which 
surround  the  hair  follicles,  the  action  of  which  has  been  described  in 
the  physiological  portion,  react  under  the  stimulus  of  cold  by  contrac- 
tion, producing  the  well-known  cutis  anserina.  This  condition  pre- 
vents cooling  by  radiation.  By  reason  of  the  contracted  condition  of  the 
cutaneous  vessels,  the  force  of  the  heart  is  intensified,  according  to  the 
law  of  Marcy;  arterial  blood  is  driven  with  more  force  through  the 


28          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

muscles,  and  the  heat-producing  capacity  of  the  latter  is  thus  enhanced. 
In  addition  to  this,  the  voluntary  muscles  usually  respond  to  the  de- 
mand for  more  heat  by  the  desire  for  motion,  which  the  influence  of 
ordinary  cold  usually  arouses.  There  is  also  a  direct  effect  upon  the 
nerve  mechanism,  conveyed  probably  from  the  sensory  nerve  endings 
which  form  the  delicate  temperature  sense  existing  in  the  skin.  The 
thermic  intrusion  upon  the  temperature-regulating  machinery  is  neu- 
tralized by  the  central  nervous  system  in  the  following  manner :  The 
spinal  cord  contains  an  excitory  and  moderating  system,  which,  accord- 
ing to  Senator,  affords  a  latitude  of  8°  to  10°  C.  for  regulating  tem- 
peratures. When  the  body  is  suddenly  exposed  to  cold,  the  excitory 
fibres  are  either  stimulated  to  action  or  a  paresis  of  the  inhibiting  fibres 
ensues.  More  heat  is  produced.  The  irritation  is  conveyed  to  motor 
tracts.  A  steady,  mild  contraction  of  the  muscles  takes  place,  which 
may  even  be  intensified  into  distinct  rigors.  Thus  a  considerable 
quantity  of  heat  may  be  developed,  which  counteracts  the  damaging 
effect  of  exposure  to  cold.  M.  Foster  says:  "Many  considerations 
have  long  led  physiologists  to  suspect  the  existence  of  a  nervous 
mechanism  by  which  afferent  impulses  arising  in  the  skin,  or  elsewhere 
might,  through  the  central  nervous  system,  originate  efferent  impulses, 
whose  effect  would  be  to  increase  or  diminish  the  amount  of  heat  gen- 
erated for  the  time  being  in  the  body." 

When,  on  the  other  hand,  the  body  is  exposed  to  high  temperatures, 
the  sensory  nerve  endings  which  form  the  temperature  sense  convey  the 
irritation  to  the  vasodilator  centre  in  the  medulla  oblongata.  An  in- 
crease of  the  large  vascular  area  in  the  skin  and  in  the  lungs  is  pro- 
duced in  response  to  this  irritation,  resulting  in  increased  exhalation 
of  moisture.  At  the  same  time  the  large  vascular  area  within  the 
abdomen,  which  is  under  the  control  of  the  splanchnic  nerve,  becomes 
narrowed.  Thus  the  circulation  of  superheated  blood  is  not  only  lim- 
ited, but  evaporation,  heat  radiation,  and  perspiration,  together  with 
the  constricted  condition  of  interior  vascular  areas,  combine  to  cool  the 
inner  part  of  the  body,  and  thus  to  counteract  the  deleterious  effect  of 
external  heat.  If  exposure  to  heat  continues,  or  increases,  the  cutane- 
ous vessels  lose  their  tone,  a  congested  state  of  the  skin  ensues,  which 
prevents  a  too  rapid  flow  of  the  heated  blood  to  the  interior  by  reason 
of  the  sluggishness  of  the  circulation  thus  induced.  The  interior  is 
not  supplied  with  the  quantity  of  blood  which  is  necessary  to  produce  the 
usual  quantum  of  heat,  and  is  thus  protected  against  being  superheated. 

Adamkiewicz  has  demonstrated  that  perspiration  may  be  induced 
by  influences  acting  upon  the  inner  vatiou  through  the  sensory  nerve 
filaments,  and  that  heat  is  a  most  powerful  reflex  irritant  for  arousing 
the  perspiration,  whether  it  be  applied  externally  or  be  generated  within 


FUNCTIONS   OF    THE   SKIN.  29 

the  body.  The  blood  cooled  by  the  perspiration  thus  induced  flows 
to  the  interior  of  the  body,  and  aids  in  preventing  an  excessive  rise  in 
temperature. 

It  is  hot  difficult  to  demonstrate  by  clinical  observation  that  the 
temperature  sense  in  the  skin  is  the  most  important  agency  in  the  reg- 
ulation of  the  body  temperature.  Burns  covering  over  two-thirds  of 
the  body  are  fatal,  because  the  terminal  sensory  fibres  of  the  skin  are 
destroyed.  By  reason  of  this  intense  effect  upon  the  central  nervous 
system,  the  vasomotor  fibres  are  brought  into  the  highest  state  of  ten- 
sion. Heat  radiation  from  the  skin  is  gradually  interfered  with,  while 
at  the  same  time  tissue  change  is  enhanced  and  production  of  heat  is 
immensely  increased.  There  being  no  regulating  influence  at  the  pe- 
riphery, the  vessels  at  the  injured  point,  even  if  they  are  not  destroyed, 
are  contracted.  Hyperaemia  of  some  of  the  internal  organs  ensues,  re- 
sulting in  the  well-known  ulcers  and  inflammations  which  destroy  life. 

Again,  large  doses  of  narcotics  which  destroy  the  sensibility  of  the 
peripheral  nerves  and  the  conducting  capacity  of  the  sensory  nerves 
favor  death  from  exposure  to  cold,  because  the  heat-regulating  centres 
do  not  receive  the  impressions  to  which  in  normal  conditions  their 
response  is  made  by  increase  of  heat  production. 

The  effect  of  thermic  irritations  of  the  cutaneous  surface  upon  the 
body  heat  has  been  investigated  by  Otto  Pospischl,  who  claims  the 
following  results : 

Driving  of  the  blood  from,  and  stoppage  of  the  circulation  in,  a 
part  diminishes  the  loss  of  heat  as  far  as  70.6  per  cent. 

The  interruption  of  the  circulation  by  the  production  of  passive 
hyperaemia  diminishes  loss  of  heat  as  far  as  46.2  per  cent. 

Mechanical  irritants  may  produce  an  increase  of  heat  loss  as  far  as 
95  per  cent. 

Weaker  chemical  irritants  may  produce  an  increase  of  heat  loss  as 
far  as  40  per  cent;  intense  irritants,  on  the  contrary,  only  to  8  per 
cent. 

Thermic  influences  which  produce  cutis  anserina  diminish  heat  loss 
as  far  as  44.5  per  cent. 

A  warm  rain  bath  may  by  this  means  induce  a  reduction  of  heat 
loss  as  far  as  38.7  per  cent. 

Partial  cold  wet  rubbing  may  increase  heat  loss  up  to  80  per  cent. 

Cold  rain  baths,  with  subsequent  rest,  produce  after  a  transitory 
diminution  of  temperature,  an  increase  of  25  per  cent. 

Cold  rain  baths,  with  subsequent  exercise,  increase  heat  loss  as  far 
as  66.6  per  cent. 

Warm  rain  baths,  with  cold  fanning  and  subsequent  rest,  increase 
heat  loss  60  per  cent. 


30          THE   PRINCIPLES   ATD   PRACTICE   OF   HYDROTHERAPY. 

In  two  cases  of  fever  the  heat  loss  during  the  rise  of  temperature 
•was  diminished  25.4  per  cent. 

If  we  accept  as  the  result  of  these  exact  investigations  the  de- 
duction that  heat  dissipation  may  be  increased  70  per  cent,  or  de- 
creased 90  per  cent,  thus  enabling  us  to  induce  compensatory  fluctua- 
tions that  may  be  three  times  the  normal,  we  have  a  ready  explanation 
why  these  compensatory  agencies  serve  to  maintain  the  constancy 
of  the  body  heat.  We  must  also  accept  the  deduction  that  in  this 
manner  may  be  explained  the  rise  of  temperature  in  fevers,  and  its 
reduction  by  the  hydriatric  procedures  described  in  another  part  of  this 
work. 

The  influence  of  thermic  agents,  externally  applied,  upon  heat  pro- 
duction and  heat  loss,  will  be  discusssed  more  fully  in  a  future  chapter. 
It  is  here  referred  to  with  a  view  to  demonstrate  the  great  importance 
of  the  skin  as  a  regulator  of  temperature  by  reason  of  its  temperature 
sense,  which  conveys  to  the  central  system  those  impressions  which 
regulate  heat  loss  in  due  proportion  to  heat  production. 


CHAPTER  III. 

PHYSICAL  PROPERTIES  OP  WATER. 

THE  physical  properties  which  render  water  capable  to  act  as  an 
agent  for  conveying  those  temperature  impressions  which  are  the  essen- 
tial elements  in  hydriatric  procedures  are : 

1st.  Its  capacity  for  gathering,  absorbing,  and  conducting  heat  and 
cold. 

That  water  possesses  a  remarkable  capacity  for  absorbing  heat 
without  being  itself  much  elevated,  and  giving  off  heat  without  losing 
itself  very  materially  in  temperature,  has  been  frequently  demon- 
strated by  experiments.  The  quantity  of  heat  required  to  raise  the 
temperature  of  one  pound  of  water  34°  suffices  to  elevate  to  the  same 
temperature  two  pounds  of  oil  of  turpentine,  eight  pounds  of  iron,  or 
thirty-five  pounds  of  mercury.  The  temperature-conducting  capacity 
of  water  is  twenty-seven  times  greater  than  that  of  air.  Water  conveys 
to  the  skin  much  stronger  thermic  impressions  than  does  air  at  the 
same  temperature,  a  fact  easily  discovered  in  exchanging  a  room  tem- 
perature at  75°  for  a  tub  bath  at  the  same  temperature. 

2d.  Its  flexibility.  The  enormous  physical  changes  which  water  is 
capable  of  accepting  as  the  result  of  different  temperatures  enhance  its 
value  as  a  flexible  thermic  agent.  At  32°  F,  water  solidifies;  at  212° 
F.,  under  ordinary  atmospheric  pressure,  it  becomes  elastic,  increasing 
seventeen  hundred  times  in  volume.  In  the  form  of  ice  it  evolves,  as 
will  be  shown,  valuable  thermic  indications  which  are  impossible  in 
other  forms.  In  the  volatile  form  of  steam  it  is  again  a  most  useful 
agent. 

By  proper  mechanical  contrivances  water  may  be  obtained  at  any 
temperature  demanded  by  the  indications  of  cases.  Its  application  is 
rendered  more  facile  than  that  of  any  other  remedial  agent  by  the 
precision  and  methodical  manner  with  which  temperature  and  duration 
may  be  graded,  as  will  be  shown  later. 

An  enormous  range  of  effect  is  evidenced  by  our  ability  to  apply 
water  at  a  temperature  equal  to  that  of  the  skin,  which  produces  an 
indifferent  effect,  and  at  that  of  ice,  which,  by  sufficiently  long  continu- 
ance, may  destroy  the  life  of  the  part,  and  in  the  other  direction  up  to 
a  temperature  sufficiently  high  to  produce  the  same  destructive  effect. 


32          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

By  remaining  within  the  range  of  safety,  we  still  have  a  large  choice 
of  temperature  (say  from  34°  to  120°  F.)  which  renders  water  a  most 
flexible  therapeutic  agent. 

3d.  The  perfect  control  which  the  chief  physical  property  of 
water — its  fluidity— affords  for  changing  the  size,  form,  and  character 
of  the  stream,  for  directing  it  to  any  one  or  all  portions  of  the  body, 
for  thus  limiting  the  local  and  general  effects  with  the  utmost  nicety 
and  precision. 

The  various  hydriatric  procedures,  full  bath,  half -bath,  sitz  bath, 
spinal  douche,  etc.,  derive  their  technique  and  application  from  this 
property  of  water. 

4th.  The  capacity  of  water  to  be  influenced  by  varying  degrees  of 
pressure  endows  it  with  power  to  produce  mechanical  effects  upon  the 
nerve  and  blood  supply  of  the  skin,  which  form  one  of  the  most  inter- 
esting and  least  appreciated  elements  of  hydrotherapy. 

By  proper  mechanical  contrivances,  which  will  be  described  in  a 
future  chapter,  water  may  be  applied  almost  without  pressure,  as  by 
a  sponge,  or  by  pouring  from  a  vessel  which  is  just  above  the  level  of 
the  cutaneous  surface ;  it  may  flow  from  a  height  with  great  force,  or 
it  may  be  driven  upon  the  skin  by  compressed  air.  Thus  may  be  pro- 
duced a  range  of  irritant  mechanical  effects  which  vary  from  the 
mildest  to  the  most  destructive.  That  a  destructive  effect  may  be 
produced  cannot  be  denied.  I  have  frequently  demonstrated  it  with 
the  filiform  douche  of  Lauriat,  by  which  a  thread-like  stream,  pro- 
pelled with  great  pressure,  can  be  made  to  penetrate  the  skin,  produc- 
ing pain  and  bleeding. 

Here  again  we  find  a  range  of  action  which  enables  the  physician 
to  produce  varied  effects  adapted  to  the  therapeutic  indications  which 
may  present  themselves. 


CHAPTER  IV. 

RATIONALE  OF  THE  ACTION  OF  WATER  IN  HEALTH. 

SINCE  water  may  be  applied  as  a  therapeutic  agent  externally  to  the 
cutaneous  surf  aces,  ^Internally  to  the  cavities  of  the  body  by  irrigation, 
and  also  with  a  view  to  absorption,  its  mode  of  action  in  health  will  be 
considered  under  these  three  heads. 

The  application  of  water  to  the  cutaneous  surface  is  the  most  im- 
portant function  of  hydrotherapy.  It  involves  chiefly  thermic  and 
mechanical  effects.  The  action  of  these,  whether  by  cold,  heat,  or 
mechanical  impact,  is  that  of  irritants  to  the  peripheral  sensory  nerves. 

(a)  This  irritation  may  be  conveyed  to  some  portions  of  the  central 
nervous  system,  and  thence  reflected  by  efferent  fibres  to  the  various 
parts  which  we  desire  to  influence. 

(b)  Changes  of  the  local  innervation  of  the  part  which  receives  the 
application  may  be  produced  by  effects  upon  the  ganglionic  centres, 
which  have  been  shown  by  Vulpian,  Golz,  and  Heidenhain  to  exist 
in  the  nerve  supply  of  the  vessels,  and  which  perform  the  function  of 
nerve  centres  within  their  immediate  sphere  without  depending  upon 
reflex  impulses  from  the  brain  or  spinal  cord. 

The  effect  of  these  nerve  irritants  depends,  like  that  of  other  irri- 
tants, upon  their  intensity,  upon  the  extent  of  surface  receiving  their 
impact,  upon  the  susceptibility  of  the  entire  organism  or  of  the  point 
of  application,  and  also  upon  the  suddenness  of  the  impact. 

The  thermic  and  mechanical  action  of  water  upon  the  circulation, 
respiration,  temperature,  tissue  change,  and  secretions,  forms  the  basis 
of  all  those  notable  therapeutic  results  which  hydrotherapy  claims. 
If  it  can  be  established  that  these  pronounced  effects  may  be  obtained 
in  health,  it  becomes  a  logical  deduction  that  they  are  useful  in  dis- 
ease, because  the  same  laws  which  govern  the  vital  processes  of  the 
organism  in  health  in  order  to  maintain  its  functions  also  are  at  work 
in  diseased  conditions,  with  the  object  of  restoring  the  lost  equilibrium. 

Just  as  in  the  study  of  medicinal  agents,  their  physiological  action 
forms  at  once  an  explanation  of  their  therapeutic  effect  and  a  guide  to 
their  application. 

Modern  hydrotherapy  does  not  ask  acceptance  of  its  clinical  results 
unless  it  can  furnish  a  fairly  clear  rationale  of  the  action  of  its  pro- 
cedures. It  is  the  aim  of  these  pages  to  lead  the  practitioner  to  the 


34          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

adoption  of  hydriatric  methods  in  all  those  conditions  in  which  they  are 
therapeutically  superior  to  medicinal  agents,  or  in  which  they  may  be- 
come auxiliaries  to  the  latter.  This  can  be  accomplished  only  by  ac- 
quainting the  practitioner  with  the  principles  which  govern  their  action. 

In  order  to  obtain  a  clear  idea  of  the  real  therapeutic  capabilities 
of  thermic  and  mechanical  irritation  applied  to  the  cutaneous  surfaces 
in  disease,  a  somewhat  detailed  account  of  our  present  state  of  knowl- 
edge of  their  influence  upon  the  most  important  functions  of  the 
organism  is  necessary. 

To  demonstrate  the  latter,  positive  experimentation  upon  animals 
and  man  has  been  made,  which  will  be  considered  under  the  following 
divisions:  Influence  of  water  applications  upon:  (1)  Circulation.  (2) 
Respiration.  (3)  Temperature.  (4)  Tissue  change.  (5)  Secretion. 

INFLUENCE  OF  HYDRIATIC  APPLICATIONS  ON  THE  CIRCULATION. 

That  system  of  animated  hydraulics  which  in  the  living  organism 
is  comprised  under  the  term  "  circulation  of  the  blood"  forms  the  great 
highway  upon  which  the  products  for  its  maintenance  and  growth  are 
conveyed,  and  by  which  the  products  of  waste  and  repair  incident  to 
the  performance  of  all  functions  are  eliminated.  It  follows,  therefore, 
that  any  agent  which  is  capable  of  exercising  even  the  slightest  influ- 
ence upon  an  apparatus  which  is  destined  for  these  important  tasks 
must  be  capable  of  exercising  in  disease  an  analogous  influence  upon 
the  organs  and  their  functions  which  come  under  the  domain  of  its 
action.  The  study  of  the  mechanical  and  thermic  action  of  water  upon 
the  circulation  will  consequently  engage  our  deepest  interest  and  atten- 
tion. It  is  proposed  to  present  under  two  distinct  heads  the  physio- 
logical effects  of  hydriatric  applications  upon  the  circulation. 

I.  Effect  upon  the  distribution  of  the  blood  and  upon  the  blood 
pressure. 

II.  Effect  upon  the  composition  of  the  blood. 

I.   EFFECT  OF  HYDRIATRIC  APPLICATIONS  UPON  THE  DISTRIBUTION 

OF  THE  BLOOD. 

The  effect  upon  the  distribution  of  the  blood  and  the  effect  upon  the 
blood  pressure  will  be  considered  together  for  obvious  reasons.  They 
may  be  subdivided,  however,  for  purposes  of  furthering  a  clear  con- 
ception of  this  important  subject  into  (a)  vasomotor  or  reflex  effects, 
(&)  mechanical  or  hydrostatic  effects. 

(a)  REFLEX  EFFECTS. — The  effects  of  water  applications  upon 
the  distribution  of  blood  have  been  studied  by  many  physiologists. 


RATIONALE    OF   THE   ACTION   OF   WATER   IN   HEALTH.  35 

Among  these  Roehrig,  who,  as  a  practising  physician  at  Kreuznach, 
had  acquired  a  large  experience  in  hydrotherapy,  furnishes*  an  elabor- 
ate and  painstaking  exposition  of  the  influence  of  cutaneous  irritants 
on  the  circulation,  which,  at  once  convincing  and  practical,  is  applica- 
ble to  the  various  modes  of  applying  water  to  the  skin. 

"  When  the  cutaneous  surface  of  an  animal  is  exposed  to  the  effect 
of  an  irritant,  an  immediate  reddening  at  the  point  of  application  en- 
sues, which  may  pass  from  a  simple  erythema  to  the  complete  death 
of  the  part.  Changes  in  the  blood-vessels  ensue,  which  may  be  ob- 
served under  the  microscope  in  the  transparent  web  or  in  the  mesentery 
of  the  frog.  When  the  back  of  the  frog  is  pricked  with  a  needle  or 
pressed  with  a  pair  of  pincers,  a  perceptible  increase  in  the  blood 
current  is  at  once  observed,  accompanied  by  a  feeble  contraction  of  the 
arteries,  and  even  of  the  veins,  lasting  a  few  seconds,  when  the  normal 
rapidity  of  the  circulation  is  restored,  together  with  a  return  to  the 
previous  calibre  of  the  vessel.  If  the  irritation  is  more  intense,  the 
narrowing  of  the  lumen  of  the  vessel  is  more  decided,  only,  however, 
yielding  to  an  equally  decided  unnatural  relaxation  of  the  muscular 
walls  of  the  vessel,  accompanied  by  a  positive  slowing  of  the  blood 
current.  The  normal  condition  following  such  irritation  is  much  more 
slow  in  returning  than  it  is  after  feeble  irritation.  The  duration  and 
intensity  of  these  effects  depend  upon  the  intensity  of  the  excitation. 
Such  experiments  demonstrate  that  feeble  cutaneous  irritants  enhance 
the  normal  tone  of  the  circulatory  muscular  fibres  of  the  vessseh,  that 
intense  irritants  permit  a  relaxation  of  the  muscular  fibres  to  follow. 
The  calibre  becomes  narrowed  either  during  the  continuance  of  the 
irritation,  or,  as  after  intense  irritation,  responds  at  once  by  a  pro- 
nounced dilatation  without  preceding  contraction. "  The  latter  may  be 
regarded,  according  to  Roehrig,  as  the  result  of  fatigue  from  over- 
stimulation,  because  the  intensity  and  duration  of  the  relaxation  of  the 
circular  fibres  corresponds  not  only  to  the  intensity  of  the  sensory 
irritation,  but  also  to  the  intensity  of  the  preceding  contraction  of  the 
artery.  In  short,  the  nervous  supply  of  the  vessel  coats  displays  the 
same  property  which  characterizes  all  other  nerves;  i.e.,  they  are 
stimulated  by  feeble  irritants  and  paralyzed  by  intense  irritants. 

"  It  has  been  clearly  shown  by  experiments  made  upon  frogs  under 
the  microscope  that  irritation  of  the  cutaneous  surface  is  conveyed 
upon  reflex  tracts  to  the  vessel  walls.  The  origin  of  the  nervous  sup- 
ply of  the  peripheral  vessels  has  been  found  in  the  vasomotor  centre 
of  the  medulla  oblongata.  When  the  latter  is  irritated,  the  small 
arteries  of  the  entire  body  are  contracted,  just  as  they  are  made  to 
contract  by  simple  excitation  of  the  sensory  nerves  themselves.  It  is 

*  "Die  Physiologie  der  Haut,  experimentell  und  kritisch  bearbeitet." 


36          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

probable  that  all  the  sensory  cutaneous  nerves  congregate  in  the  vaso- 
motor  centre  in  the  medulla,  where  they  are  connected  with  the  vaso- 
motors  of  all  the  arteries  of  the  body.  From  this  central  point  an  in- 
cessant influence  goes  out,  acting  upon  the  contractility  of  all  arteries 
and  probably  with  greater  intensity  upon  the  peripheral  vessels.  A 
continued  tonic  action  is  thus  maintained,  which  produces  'arterial 
tone,'  and  partly  furnishes  that  resistance  at  the  periphery  which  is 
so  essential  in  maintaining  the  force  of  the  heart,  and  in  governing 
the  blood  pressure  and  blood  distribution.  That  these  important 
factors  in  the  circulation  may  be  readily  affected  by  irritation  of  the 
sensory  cutaneous  nerves  has  been  illustrated  by  experiment.  But 
there  are  deeper  and  more  far-reaching  results  traceable  to  action  upon 
the  external  surface  of  the  body,  which  are  of  great  importance  in 
explaining  the  effects  of  thermic  cutaneous  irritation,  and  consequently 
also  the  effects  of  many  hydriatric  procedures.  Maximilian  Schilller's 
experiments  on  trephined  rabbits*  demonstrate  that  the  nerves  supply- 
ing the  vessels  of  the  pia  mater  experience  a  steady  'tonic'  excitation 
from  the  cutaneous  sensory  nerves.  When  Schilller  severed  single 
nerve  trunks  on  one  side  of  a  trephined  rabbit,  he  always  observed  an 
evanescent  but  very  distinct  dilatation  of  the  pial  vessels  on  the  corre- 
sponding side.  That  this  result  was  not  due  to  pain  was  evident  from 
the  fact  that  the  other  side  remained  unchanged.  This  result  proved 
clearly  that  the  changes  in  the  excitation  referred  to  above,  produced 
by  thermic  or  mechanical  irritation  of  the  cutaneous  nerves,  would 
disturb  the  vascular  equilibrium  in  the  brain.  Not  alone  the  nerves 
supplying  the  vessels  experience,  according  to  Schuller,  this  reflex  exci- 
tation going  out  from  the  cutaneous  sensory  nerves,  but  he  believes  that 
the  centres  for  heart  and  respiratory  movements  receive  it  perhaps  to 
a  greater  degree.  Clinical  observation  exemplifies  this  effect  also  on 
man." 

Goltz,  also,  has  shownf  how  the  action  of  the  heart  may  be  influ- 
enced by  excitation  of  the  sensory  nerves  by  means  of  reflex  action. 
Mechanical  irritation  of  the  exposed  intestines  of  a  frog  by  a  simple 
blow  caused  cessation  of  cardiac  action  in  diastole,  and  this  result  did 
not  follow  when  the  reflex  tracts  were  interrupted  by  destroying  the 
medulla  oblongata  or  by  cutting  the  vagus  nerves. 

The  action  of  the  heart  is,  as  is  well  known,  decidedly  increased 
in  high  atmospheric  temperatures,  while  low  temperatures  diminish 
it.  Roehrig  has  made  numerous  experiments  of  the  effect  produced 
upon  cardiac  activity  by  excitation  of  the  sensory  cutaneous  nerves, 
all  of  which  demonstrated  that  the  heart  muscles  respond  with  great 

*  Deutches  Archiv  fur  klinische  Medicin,  No.  4,  1874. 

f  "Tonus  der  Gefasse,"  etc.,  in  "Virchow's  Archiv,  Bd.  xviv. 


RATIONALE   OF   THE   ACTION   OF   WATER   IX   HEALTH.  37 

sensitiveness  to  all  kinds  of  stimulation  applied  to  the  cutaneous 
nerves.  Feeble  stimulants  not  only  invariably  modify  the  energy  of 
cardiac  contractions,  but  also  increase  their  number,  while  intense 
cutaneous  stimulants  not  only  enhance  the  force  of  the  contractions, 
but  also  reduce  their  frequency  considerably.  These  eifects  depend 
not  only  upon  the  intensity  of  the  excitation,  but  also  upon  the  extent 
of  the  cutaneous  surfaces  irritated.  Roehrig  also  experimented  with 
thermic  irritants.  He  applied  a  paper  tube  filled  with  ice  for  fifteen 
minutes  to  the  inside  of  the  ear  of  a  rabbit,  with  the  result  that  the 
intense  cooling  of  the  ear  produced  an  increase  of  tAvelve  to  eighteen 
beats  in  the  pulse.  On  the  other  hand,  the  application  of  water  at 
1569  to  158°  F.  caused  an  immediate  increase  of  ten  to  twelve  beats, 
which  was,  however,  followed  by  a  decided  fall,  amounting  to  seventy 
beats  below  the  normal  (the  normal  heart  beat  being  150  to  170).  The 
heart  recovered  slowly,  after  the  expiration  of  two  hours,  in  both 
experiments.  Roehrig  also  ascertained  by  proper  experiments  that, 
when  intense  cutaneous  irritants  produce  considerable  slowing  of  the 
heart,  they  also  increase  its  force.  These  results  are  undoubtedly  brought 
about  by  reflex  action,  as  experiments  by  cutting  the  sympathetic  and 
vagus  in  different  animals  have  demonstrated  that  the  slowing  of  the 
pulse  is  due  to  an  excitation  of  the  pneumogastric  nerve,  which  in  ex- 
treme cases  caused  death  by  tetanic  contraction  of  the  heart.  The 
animals  died  in  convulsions,  with  gradual  paling  of  the  fundus  oculi, 
as  observed  in  albino  rabbits,  which  died  with  open  eyes.  There  was 
doubtless  an  interruption  of  the  blood  supply  to  the  brain  and  to  the 
spinal  cord. 

A  direct  effect  upon  the  continuity  of  the  vessels  was  formerly 
regarded  as  the  only  channel  by  which  irritants  produced  local  exter- 
nal hypersemia.  It  was  supposed  that  the  accumulation  of  blood  on 
the  surface  after  blisters  or  rubefacients  withdrew  blood  whose  fluxion 
to  internal  organs  was  pathological,  and  thus  proved  antiphlogistic. 
This  fallacy  was  exposed  by  the  investigations  of  Naumann,  which 
have  become  classical. 

Naumann  has  demonstrated  clearly  that  the  effects  of  external 
irritants  upon  the  circulation  within  the  body  are  really  reflex.  He 
separated  the  head  of  a  frog  from  the  body,  leaving  them  connected 
by  the  medulla  oblongata  only.  He  next  severed  one  leg,  after  pre- 
venting loss  of  blood  by  tying  the  vessels,  so  as  to  leave  it  connected 
with  the  body  by  the  sciatic  nerve.  Now  he  applied  thermal, 
chemical,  and  electric  stimuli  to  the  foot  of  the  partially  severed  leg, 
while  he  observed  under  the  microscope  the  mesentery  of  the  frog. 
Shortly  after  gentle  irritation  of  the  peripheral  endings  of  the  sciatic 
nerve  in  the  foot,  the  circulation  in  the  vascular  network  of  the  lungs 


38          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

and  mesentery  was  accelerated,  and  resumed  the  former  condition 
slowly  after  the  withdrawal  of  the  irritant.  A  more  severe  irritation 
produced  retardation  of  the  flow,  and  even  stasis  occurred,  as  if  the 
heart  had  become  temporarily  paralyzed.  A  strong  irritant  produced 
dilatation,  a  feeble  one  constriction  of  the  vessels.  The  effect  of  these 
peripheral  irritations  upon  the  heart  was  also  noted.  A  strong  irrita- 
tion of  the  skin  weakened  its  circulation ;  a  feeble  irritant  strength- 
ened it.  As  there  was  no  possible  vascular  or  nerve  channel  from  the 
part  irritated  to  the  part  thus  visibly  affected,  the  conclusion  is  inevi- 
table that  the  effect  is  entirely  reflex.  Hot  water  acted  precisely  in 
the  same  manner  as  other  irritants.  Naumann  continued  his  investiga- 
tions upon  warm-blooded  animals  and  upon  man  with  the  same  results, 
and  announced  his  conclusions  as  follows : 

"  The  effect  of  epispastics  is  essentially  due  to  reflex  action  through 
the  central  organ ;  they  exert  considerable  influence  upon  the  activity 
of  the  heart  and  vessels. 

"  In  proportion  to  the  irritability  of  the  individual,  powerful  con- 
tinuous stimuli  lessen  the  activity  of  the  heart  vessels  and  weaken 
contraction,  the  vessels  becoming  dilated  and  the  circulation  slower; 
relatively  weak  stimulation  increases  the  activity  of  the  heart  and 
vessels,  strengthens  cardiac  contraction,  narrows  the  vessels,  and 
accelerates  the  circulation. 

"  The  changes  produced  in  the  body  by  long-continued  cutaneous 
stimulation  last  a  considerable  time  after  the  conclusion  of  the  same, 
as  a  general  rule;  the  more  enduring  the  stimulation  applied,  the 
longer  they  will  last,  and  in  a  healthy  person  will  often  still  be  per- 
ceived after  the  lapse  of  from  half  to  three-quarters  of  an  hour  from 
the  conclusion  of  the  stimulation. 

"  The  relaxation  of  the  pulse  which  follows  a  more  powerful  cutane- 
ous stimulation  often  attains  its  maximum  during  the  stimulation,  but 
frequently  only  after  the  conclusion  of  the  same. 

"  The  excitant  action  of  a  relatively  weak  cutaneous  stimulation  like- 
wise continues  for  a  considerable  time  after  it  has  been  removed,  but 
it  is  finally  also  followed  by  a  relaxation,  only  this  appears  much  later 
and  in  a  less  degree  than  after  more  powerful  cutaneous  stimulation. 

"  As  a  consequence  of  stronger  cutaneous  stimulation,  there  con- 
stantly appears,  mostly  after  a  longer  or  shorter  period  of  warming,  a 
cooling  down  of  the  body,  which  often  does  not  terminate  until  half  an 
hour  after  the  cessation  of  the  stimulus. 

"This  period  of  alteration  in  temperature  is  of  varying  duration; 
cooling  ofttimes  takes  place  during  the  stimulation,  but  as  a  rule  only 
after  its  conclusion." 

There  are  tivo  modes  of  effecting  changes  in  the  circulation)  by  re" 


RATIONALE   OF  THE   ACTION   OF   WATER   IN    HEALTH.  39 

flex  excitation  from  the  sensory  nerves,  namely,  one  influencing  the 
calibre  of  the  vessel  and  the  other  acting  upon  the  propulsive  power  of 
the  heart  muscle.  Without  entering  into  the  details  of  experiments 
made  by  Bezold,  Ludwig,  and  Roehrig,  it  may  be  safely  stated  that  the 
enhanced  arterial  pressure  and  rapidity  of  the  blood  stream  following 
the  narrowing  of  the  vessels  produced  by  weak  cutaneous  irritants  is 
not  induced  by  an  increased  propulsive  power  of  the  heart,  because 
these  effects  are  produced  also  when  all  the  nerves  leading  to  the  heart 
are  cut  off.  It  is  clear  that  a  stasis  of  blood  ensues  in  the  arterioles 
as  the  result  of  the  contraction  of  their  terminals,  and  that  increase  of 
blood  in  them  is  really  due  to  the  prevention  of  the  outflow  of  blood 
from  these  contracted  vessels,  and  that  this  heightened  pressure  is  not 
chargeable  to  increased  activity  of  the  heart,  but  secondarily  to  the 
increased  resistance  of  the  stream  at  the  periphery. 

Following  the  process  to  an  extreme  point  we  find  that  by  intensely 
low  temperatures  the  circulation  in  the  capillaries  is  at  first  accelerated 
and  the  number  of  blood  corpuscles  diminished,  when  the  part  be- 
comes pale.  Quickly  following  this  acceleration  there  is  a  stasis  in 
the  capillaries,  while  in  the  smaller  veins  and  arteries  the  slowing  of 
the  circulation  is  followed  by  brief  and  rapid  oscillations,  which  be- 
come slower  and  more  infrequent.  Slowly  the  vessels  become  more 
pale,  less  transparent,  and  finally  the  movements  cease,  until  the  ves- 
sel is  blocked  and  occluded. 

When  the  cold  is  less  intense  and  more  prolonged,  there  ensues  a 
retardation  of  the  stream  in  the  smaller  capillaries,  while  it  becomes 
more  active  in  the  larger  vessels,  which  now  dilate.  If,  however,  the 
application  is  continued,  the  larger  vessels  are  also  contracted  and 
blocked.  A  collateral  hyperaemia  in  neighboring  parts  is  the  result, 
which  produces  more  rapid  circulation  in  them. 

It  is  not  difficult  to  deduce  the  most  important  physiological 
changes  as  the  result  of  this  energetic  influence  of  cold  upon  the 
vessels,  as  will  appear  farther  on. 

To  summarize  :  "  Weak  cutaneous  irritants  produce  a  narrowing  of 
the  small  arterioles,  with  a  rise  of  pressure,  in  consequence  of  which, 
by  the  intensifying  of  the  resistance  at  the  periphery,  the  heart  is 
made  to  contract  more  vigorously.  Intense  cutaneous  irritants,  on  the 
contrary,  fatigue  and  paralyze  the  normally  existing  innervation  of  the 
blood-vessels  which  emanates  from  the  medulla  oblougata.  These 
produce  a  relaxation  and  dilatation  of  the  peripheral  arteries  with 
diminution  of  pressure,  but  at  the  same  time  the  inhibitory  action  of 
the  pneumogastric  is  enhanced,  producing  a  slowing  and  intensifying 
of  cardiac  contraction,  which  may,  when  excessive,  even  produce  death 
by  vagus  tetanus." 


40          THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

The  important  functions  resulting!  from  irritation  of  the  sensory 
nerves  in  the  skin  should  be  carefully  borne  in  mind,  since  they  possess 
great  practical  significance  in  many  hydriatric  procedures,  whose  aim  it 
really  is  to  produce  thermic  irritations  in  varying  degrees.  The  degree 
of  heat  or  cold  in  any  hydriatric  procedure,  the  amount  of  pressure 
with  which  it  is  delivered,  the  previous  condition  of  the  patient, 
whether,  for  instance,  his  skin  is  in  an  ordinary  condition  or  has  just 
emerged  from  an  air  bath  of  150°  F. ,  or  comes  from  a  room  contain- 
ing air  at  the  ordinary  temperature;  whether  the  temperature  of  the 
douche  is  suddenly  or  gradually  lowered — all  these  modify  the  thermic 
and  mechanical  irritation  of  the  sensory  nerve  terminals.  The  effects 
produced  by  them  depend  upon  the  principles  demonstrated  by  the 
experiments  of  Eoehrig  and  Naumann,  here  detailed,  and  which  have 
been  abundantly  confirmed  by  others. 

(b)  HYDROSTATIC  EFFECTS. — That  the  effect  of  hydriatric  applica- 
tions upon  the  distribution  of  blood  is  not  reflex  only  but  to  a  certain 
extent  also  hydrostatic  is  clearly  demonstrated  by  the  experiments  of 
Maximilian  Schuller,*  who  trephined  rabbits,  carefully  exposing  to  view 
the  vessels  of  the  pia  mater,  without  disturbing  the  dura,  which  by  its 
transparency  facilitated  his  observation.  He  carefully  noted  the  nor- 
mal circulation  of  these  vessels,  and  ascertained  that  even  simple  pres- 
sure upon  the  belly  produced  dilatation  of  the  veins,  and  sometimes 
also  of  the  arteries,  probably  through  mechanical  interruption  of  the 
venous  return  flow.  When  he  applied  pieces  of  ice  upon  the  dura 
mater,  he  observed  very  energetic  contraction  of  the  veins  and  arteries 
of  the  pia,  which  continued  half  a  minute  even  after  removal  of  the  ice. 
The  most  interesting  observation,  however,  was  that  when  he  placed 
cold  wet  compresses  upon  the  belly  of  the  rabbit  the  vessels  of  the  pia 
mater  invariably  dilated,  cerebral  pulsation  became  more  pronounced 
and  slower,  and  respiration  was  deepened  and  slowed.  These  phe- 
nomena continued  a  short  time  after  removal  of  the  compresses,  and 
they  were  followed  by  transient  narrowing  and  a  return  to  the  normal 
calibre.  When  warm  compresses  were  applied,  the  arteries  and  veins  of 
the  pia  mater  contracted,  the  pulsations  became  less  pronounced  and 
more  frequent,  and  respiration  more  shallow  and  rapid. 

By  changing  the  temperature  of  the  compresses  these  changes  were 
more  or  less  rapidly  produced.  A  very  hot  compress  produced  the 
same  effect  as  a  cold  compress.  These  manifestations  were  also  ob- 
served, but  with  more  pronounced  effect,  after  immersion  of  the  entire 
body  into  cold  or  hot  water ;  the  effect  being  exactly  in  the  proportion 
to  the  extent  of  surface  immersed.  After  a  prolonged  immersion  in 
cold  water  a  narrowing  of  the  vessels  and  sinking  of  the  brain  sub- 
*  Deutsches  Archiv  f ilr  klinische  Medicin,  xiv. 


RATIONALE   OF  THE  ACTION   OF  WATER   IX   HEALTH.  41 

stance  ensued,  due,  doubtless  to  the  reduction  of  temperature  in  the 
circulating  blood,  Avhich  approximated  in  effect  to  that  produced  by 
local  ice  application.  The  vessels  of  the  ear  also  participated  in  this 
effect.  Immersion  in  warm  water  produced  a  transient  dilatation, 
which  was  followed  by  a  vigorous  narrowing  of  the  vessels  and  sink- 
ing of  the  brain  substance.  The  cerebral  movements  became  at  first 
accelerated,  afterward  slower  and  more  shallow,  finally  becoming  more 
rapid,  when  the  temperature  of  the  water  was  elevated. 

Immersion  into  very  hot  baths  produced  effects  similar  to  hot  com- 
presses, but  of  greater  intensity  and  duration. 

Under  either  the  cold  or  the  warm  douche  the  cerebral  circulation 
did  not  vary  greatly. 

Cold  rectal  enemata  always  produced  a  moderate  dilatation  of  the 
cerebral  vessels. 

Schiiller  has  placed  hydrotherapy  under  lasting  obligations  by  the 
pains  taken  in  his  observations. 

The  great  importance  of  his  experiments  and  of  his  deductions 
warrants  the  writer  in  presenting  them  in  detail,  inasmuch  as  the  clear 
expositions  furnished  by  Schuller  supply,  if  they  are  interpreted  logi- 
cally and  without  prejudice,  a  clew  to  many  misapprehended  phenom- 
ena in  hydrotherapy. 

From  all  his  experiments,  Schuller  regards  it  as  undoubtedly  estab- 
lished that  the  changes  referred  to  as  taking  place  in  the  vessels  of 
the  pia  and  in  the  fulness  of  the  brain  during  and  in  consequence  of 
the  varied  applications  of  water,  and  which  have  been  shown  to  be  al- 
ways constant  in  a  very  large  number  of  animals,  may  be  positively  ac- 
cepted as  the  true  expression  of  changed  physiological  relations.  The 
occurrence  of  the  characteristic  changes  in  curarized  animals  also  must 
set  aside  every  objection  to  their  being  accidental.  Indeed,  it  may 
be  regarded  as  proved  that  a  causal  connection  certainly  exists  between 
the  various  external  applications  of  water  and  the  typical  changes  in  the 
vessels  of  the  pia. 

In  explaining  these  results,  that  is,  the  dilatation  of  the  pial  vessels 
by  cold  applications  to  the  surface  of  the  animal  and  their  narrowing 
by  warm-water  applications,  the  first  thought  would  be,  according  to 
the  usual  ideas,  that  they  arise  from  an  influence  of  the  thermic  irri- 
tation upon  the  nerves  of  the  vessels  or  upon  the  vessels  of  the  nerve 
centres.  But  Schiiller's  experiments  in  irritating  the  nerves  them- 
selves, have  shown  that  such  effects  differ  entirely  from  those  obtained 
in  the  original  experiment.  When  he  placed  a  piece  of  sponge  satu- 
rated in  water  of  9D  R.  (52°  F.)  upon  the  trunk  of  a  cutaneous  nerve  a 
transient  narrowing  of  the  vessels  of  the  pia  occurred,  while  a  com- 
press of  the  same  temperature  placed  upon  the  belly  or  back  of  the 


42  THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

animal  always  produced  a  prolonged  and  decided  dilatation.  The  ap- 
plication of  water  at  30°  R.  (99.5  F.)  upon  the  cutaneous  nerve  trunk 
produced  widening  of  the  vessels,  while  the  same  applied  upon  the  gen- 
eral skin  produced  narrowing.  Therefore  thermic  irritation  of  the 
sensory  cutaneous  nerve  trunks  produced  changes  in  the  vessels  of 
the  pia  directly  opposite  to  those  applied  upon  the  skin  in  general. 
Hence  the  typical  changes  of  the  vessels  of  the  pia  after  applications  of 
water  to  the  periphery  cannot  be  ascribed  exclusively  to  reflex  excitation 
from  the  cutaneous  nerves. 

Moreover,  compresses  of  varied  temperatures  always  produced  de- 
cided changes  in  the  blood  pressure ;  namely,  cold  water  produced  a 
strong  rise  of  blood  pressure  in  the  carotid,  warm-water  applications  a 
relative  sinking  of  the  same.  This  positively  ascertained  fact  cannot 
be  reconciled  with  the  idea  of  an  essentially  reflex  influencing  of  the 
pial  vessels  by  water  applications;  for  if  the  latter  were  accepted  we 
should  be  forced  to  explain  the  widening  of  the  pial  vessels  folloAving 
cold-water  application  upon  the  skin  by  a  reflex  paralysis  of  the  vaso- 
motor  nerves  of  the  brain.  Inasmuch,  however,  as  paralysis  of  vaso- 
motor  nerves  or  of  the  vasomotor  centre  is  always  connected  with  a 
decided  fall  of  pressure  in  the  arteries,  while  on  the  other  hand  cold- 
water  applications  are  constantly  followed  by  a  rise  of  blood  pressure, 
this  simultaneously  occurring  dilatation  of  the  pial  vessels  can  in  no 
way  be  attributed  to  a  reflex  paralysis  of  the  vasomotor  nerves. 

These  apparently  irreconcilable  contradictions,  that  is,  the  dilating 
of  the  pial  vessels  under  cold  applications  upon  the  skin  and  their  nar- 
rowing when  the  applications  are  made  upon  the  sensory  nerve  trunks, 
as  also  the  rise  of  blood  pressure  with  simultaneous  dilatation  of  the 
pial  vessels  and  of  the  vessels  of  the  ear,  may  be  very  readily  explained 
in  a  satisfactory  manner  if  we  assume  that  the  cold-water  application 
upon  the  skin  produces  contraction  of  its  peripheral  vessels  in  conse- 
quence of  which  the  remaining  vessels  of  the  body  are  filled  with  more 
blood.  Moreover,  inasmuch  as  every  interference  with  the  blood  flow 
(in  this  instance  the  large  area  of  capillaries  in  the  skin)  raises  the 
tension  of  the  arteries  behind  it,  we  have  herein  also  an  explanation 
of  the  rise  of  blood  pressure.  The  fact  that  during  the  full  bath  the 
filling  of  the  pial  vessels  increased  according  to  the  dimensions  of  the 
part  of  the  animal  which  was  dipped  into  cold  water,  and  the  fact  that 
the  vessels  of  the  ear  also  filled  more  completely  when  the  ears  were 
kept  out  of  the  water,  and,  finally,  that  the  dilatation  of  the  pial  vessels 
increased  still  more  when  the  ears  were  also  dipped  into  the  water, 
taken  in  connection  with  the  above-mentioned  observations,  point  to 
but  one  explanation,  namely,  that  the  cause  of  the  dilatation  of  the 
pial  vessels  under  cold-water  applications  is  to  be  found  in  a  retrostasis 


RATIONALE   OF   THE  ACTION   OF  WATER   IN   HEALTH.  43 

of  the  blood  into  the  interior  consequent  upon  the  narrowing  of  the 
vascular  area  of  the  skin.  A  similar  explanation  of  the  narrowing  of 
the  pial  vessels  under  warm-water  applications  is  justified,  namely, 
that  the  relaxation  and  consequent  filling  of  the  cutaneous  vessels 
are  followed  by  a  simultaneous  diminution  of  fulness  in  the  remaining 
vascular  area,  consequently  also  in  the  vessels  of  the  brain.  The  rela- 
tive reduction  of  the  blood  pressure  agrees  with  this  explanation,  be- 
cause the  brief  initial  rise  of  pressure  may  be  explained  by  the  increased 
rapidity  of  the  heart's  action. 

Schilller  does  not  deny  that  there  is  an  influence  upon  the  nerves 
under  these  applications.  On  the  contrary,  he  regards  it  as  indubi- 
table that  the  cutaneous  nerve  terminals  are  affected  in  the  same  way 
by  thermic  influences  as  the  cutaneous  vessels,  and  that  it  is  very 
probable  that  these  nerve  filaments  are  affected  in  the  same  way  as 
their  trunks;  namely,  that  cold  applications  arouse  reflex  narrowing, 
warm  applications  reflex  dilatation  of  the  pial  vessels.  This  seemingly 
contradictory  effect  must  undoubtedly  limit  the  characteristic  changes 
of  the  pial  vessels  when  water  is  applied  to  the  skin,  and  to  it  is  prob- 
ably attributable  the  rapidly  changing  alternation  of  calibre  in  the 
pial  vessels  observed  in  the  beginning  of  the  water  application  before 
the  characteristic  dilatation  or  narrowing  ensues.  In  other  words, 
Schilller  believes  that  in  the  beginning  of  the  application  the  pial 
vessels  are  affected  by  reflex  irritation  from  the  cutaneous  nerves,  and 
that  the  real  effect  upon  the  pial  vessels  occurs  only  when  the  thermic 
influence  upon  the  cutaneous  vessels  has  gained  the  ascendancy. 

The  fact  that  cutting  the  cervical  portion  of  the  spinal  cord  pre- 
vented the  occurrence  of  any  effect  upon  the  pial  vessels  under  water 
applications  does  not  weigh  against  the  assumption  that  we  have  here 
to  deal  with  a  hydrostatic  effect.  After  the  section  of  the  cord  not  only 
is  there  an  interruption  of  reflexes  from  peripheral  thermic  irrita- 
tions upon  the  nerves  supplying  the  pial  vessels,  bxit  the  tone  of  all  the 
muscular  coats  of  the  vessels  is  essentially  destroyed;  consequently, 
also,  that  of  the  cutaneous  vessels.  Under  these  conditions  no  effect 
whatever  can  be  produced  upon  the  distribution  of  the  blood  under 
water  applications ;  indeed,  the  blood  of  the  entire  body  remains  in  a 
positive  equilibrium,  because  none  of  the  vessels  respond  on  account  of 
loss  of  tone. 

The  action  of  the  heart  and  the  respiratory  movements  which  influ- 
ence the  circulation  of  the  brain  more  or  less  in  ordinary  conditions 
are  of  little  importance  in  this  connection.  Schilller  found  that  after 
section  of  the  vagus,  the  pial  vessels  were  not  quite  so  full;  but  the 
typical  changes  resulting  from  water  applications  ensued  just  as  plainly 
as  when  the  vagus  was  intact. 


44          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

Schuller  summarizes  the  characteristic  action  upon  the  pial  vessels 
by  water  applications  as  follows: 

These  changes  are  due  essentially  to  the  increased  or  diminished 
afflux  of  blood  to  the  pial  vessels  in  consequence  of  the  narrowing  or 
dilatation  of  the  peripheral  vessels  in  the  skin. 

The  movements  of  the  heart  and  respiration  are  only  indirectly 
concerned;  they  sometimes  further  or  limit  these  changes. 

The  reflex  influences  of  the  thermic  irritation  of  the  cutaneous 
nerves  upon  the  pial  vessels  are  of  subordinate  importance  (in  the  pro- 
cedure used  by  Schiiller  [author]) ;  if  they  produce  any  effect  they  prob- 
ably limit  these  manifestations. 

Secondary  Effects  of  Water  Applications. — The  experiments  of 
Schuller  further  show  that  the  effects  described  as  arising  from  cold 
and  warm  external  applications  do  not  continue  if  the  latter  are  pro- 
longed. These  effects  last  only  two  to  three  minutes  after  compresses, 
five  to  ten  minutes  after  baths.  In  general  they  are  of  shorter  dura- 
tion after  cold  than  after  warm  applications.  Frequent  repetition  of 
the  application  does  not  change  the  effect.  It  occasionally  increases  it 
after  cold  applications,  but  shortens  its  duration.  After  the  above 
period,  whether  the  application  be  discontinued  or  prolonged,  Schuller 
observed  constant  changes  of  the  vessel  calibre,  ivhich  are  the  reverse 
of  the  initial  chanycs  ;  if  the  pial  vessels  were  dilated  by  cold  applica- 
tions, they  now  became  contracted,  and  vice  versa.  When  the  appli- 
cation is  interrupted  after  short  duration,  the  vessels  assiime  their 
noimal  character;  when  the  application  is  continued  very  long,  the 
constriction  mostly  increases.  Schtiller's  observations  demonstrate 
without  doubt  that  in  these  secondary  changes  in  the  pial  vessels  oppo- 
site conditions  prevail  in  a  minor  degree;  viz.,  that  the  cutaneous 
vessels  fill  after  cessation  of  or  upon  continuation  of  the  cold. 
Schuller  claims  that  when  the  application  is  of  long  duration,  the 
relatively  intense  cooling  of  the  blood  conduces  to  prolonged  narrowing 
of  the  pial  vessels ;  cooler  blood  circulating  in  the  pial  vessels  causes 
contraction  of  their  coats,  especially  after  full  baths,  which  effect  is 
more  pronounced  in  rabbits  because  their  surface  is  relatively  larger 
than  their  mass.  The  secondary  effect  upon  the  pial  vessels  produced  by 
warm-water  application  may  be  explained  in  a  similar  manner.  When 
the  bath  is  prolonged  the  blood  flows,  owing  to  diminished  heat  dissi- 
pation, at  a  relatively  higher  temperature  to  the  pial  vessels,  and  pro- 
duces dilatation  of  the  previously  contracted  vessels,  by  reason  of 
paralysis  of  the  vasomotor  nerves  of  the  cerebral  vessels.  If  the  warm 
application  be  discontinued,  the  cutaneous  vessels  are  again  narrowed, 
and  the  blood  is  again  driven  in  larger  quantities  to  the  pial  vessels ; 
hence  we  have  dilatation,  which  gradually  ceases  as  the  blood  distri- 
bution becomes  equalized.  Schuller  holds  that  this  is  the  explanation 


RATIONALE   OF   THE   ACTION   OF   WATER   IN    HEALTH.  45 

of  the  dilatation  ensuing  upon  cessation  of  the  warm- water  application, 
because,  if  cold  water  be  applied  immediately  afterward,  the  dilatation 
is  increased  by  reason  of  increase  of  the  contraction  of  the  cutaneous 
vessels,  a  larger  quantity  of  blood  being  thus  driven  from  the  capillary 
area  of  the  skin  to  the  internal  organs. 

These  explanations  of  the  contrary  secondary  effects  of  water  ap- 
plication, made  by  Schuller,  do  not  appear  quite  satisfactory  to  the 
author.  I  believe  that  Schuller' s  original  explanation  that  the  pri- 
mary effect  is  chiefly  hydrostatic  also  holds  in  the  rationale  of  these 
opposite  secondary  effects.  Indeed  the  latter  add  proof  to  the  hydro- 
static action  which  would  not  have  escaped  Schuller  had  he  been 
familiar  with  hydrotherapy.  That  "these  effects  last  only  two  or 
three  minutes  after  compresses,  live  to  ten  minutes  after  baths "  is 
readily  accounted  for  by  the  fact  that  after  the  compress  has  by  nar- 
rowing the  capillary  area  beneath  it  driven  the  blood  into  the  interior 
vessels,  reaction  ensues,  the  arterioles  become  distended  under  the 
heightened  pressure  and  blood  flows  more  rapidly  into  the  previously 
aneemized  capillaries,  dilating  them  beyond  their  former  calibre  (in 
the  human  subject  this  is  evidenced  by  reddening  of  the  skin).  This 
hyperaeinia  in  the  cutaneous  vessels  gives  rise  to  the  diminution  of  the 
calibre  of  the  pial  vessels — a  hydrostatic  effect  in  precise  imitation  of 
a  warm  compress.  If  the  low  temperature  of  the  skin  is  maintained, 
reaction  ensues  "  after  a  bath  of  five  to  ten  minutes,"  the  cutaneous 
vessels  fill  and  the  pial  vessels  contract. 

When  warm  applications  to  the  skin  are  followed  by  contraction  of 
the  pial  vessels,  and  this  ceases  with  cessation  of  the  application,  the 
vessels  returning,  as  Schuller  shows,  to  the  normal,  J.  believe  that  a 
rational  explanation  may  be  found  in  the  fact  that  when  the  skin  is  ex- 
posed after  the  warm  application  to  the  temperature  of  the  air,  which 
is  always  much  below  that  of  a  warm-water  application,  the  cutaneous 
vessels  contract  by  reason  of  this  change  of  temperature  until  they 
reach  a  normal  calibre.  Hence  the  pial  vessels  also  assume  a  normal 
calibre.  Schuller's  observation  that  prolonged  maintenance  of  the 
temperature  of  the  warm  application  produces  an  increasing  constric- 
tion of  the  pial  vessels  may  be  explained  by  the  complete  relaxation 
of  the  cutaneous  vessels,  producing  a  passive  condition  which  admits 
much  more  blood  than  it  did  at  first. 

Schuller  justly  claims  that  his  investigations  made  by  experiments 
on  animals  must  prove  of  great  value  in  the  practical  conception  of 
the  effect  of  water  applications  in  man,  and  that  if  they  can  be  applied 
to  the  human  organism  they  will  tend  to  modify  or  overthrow  certain 
indefinite  ideas  upon  the  subject,  and  substitute  these  more  positive 
ones.  That  the  results  of  these  experiments  are  applicable  to  the 
human  organism'also  admits  of  no  doubt.  Although  the  anatomical 


46  THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

structure  of  the  skin  and  the  relation  of  the  cutaneous  nerves  to  the 
central  nervous  system  in  man  differ  from  those  of  the  rabbit,  the 
effect  of  water  applications  is  modified  only  to  a  slight  extent.  The 
effect  is  the  same.  Indeed,  the  conditions  are  even  more  favorable  in 
man,  because  his  skin  and  cellular  tissue  are  supplied  with  more  blood- 
vessels, a  more  active  muscular  structure,  and  more  abundant  lymph 
vessels  with  muscular  walls.  The  constringing  effect  of  cold  upon 
the  superficial  veins  must  also  be  reckoned  with.  It  is  singular  that 
this  fact  is  not  referred  to  by  even  the  most  conscientious  students  of 
this  important  phase  of  hydrotherapy.  I  desire,  therefore,  to  em- 
phasize here  the  anatomical  fact  that  the  musculature  of  the  super- 
ficial veins,  especially  of  the  lower  extremities,  is  fairly  well  de- 
veloped,* and  that  "  flattened  and  circular  muscular  cells  exist  in  the 
valves."  Schlesinger  f  has  observed  "that  pathologically  dilated 
veins  in  the  lower  extremities  may  be  converted  into  cords  by  intense 
cold  applications." 

The  local  temperature  effect  is  intensified  by  the  presence  of  smooth 
muscular  fibres  in  the  corium,  which  enables  the  skin  to  respond  more 
readily  to  cold  applications.  If  the  effect  upon  this  large  abundantly 
anastomosing  network  of  cutaneous  vessels  is  taken  into  consideration, 
it  may  easily  be  conceived  how  contractions  by  cold  and  relaxations  by 
warmth  conveyed  to  it  by  water  may  induce  considerable  fluctuations 
in  the  blood  supply  of  the  remaining  vascular  system.  The  effect  of 
cold  and  warm  baths  upon  the  nervous  system  has  too  often  been 
noted  to  require  to  be  cited  in  evidence  of  this  proposition. 

The  observations  of  Schilller  detailed  above  have  been  confirmed  in 
man  by  Dr.  Vinaj,  who  utilized  for  this  purpose  a  man  who  had  lost  a 
portion  of  his  cranium  through  a  severe  injury.  Vinaj  presented  his 
observations  to  the  Fourth  Italian  Congress  for  Hydrology,  held  at 
Florence  on  the  21st  of  November,  1892,  stating  that  they  entirely 
corroborated  the  results  obtained  by  Schilller  in  animals. 

From  these  simple  explanations  it  becomes  clearly  evident  that, 
while  the  local  influence  of  warmer  or  cooler  blood  upon  the  pial  ves- 
sels themselves  may  have  a  share  in  the  opposite  secondary  effects  re- 
ferred to,  the  hydrostatic  principle  holds  here  also. 

I  have  dwelt  so  fully  upon  this  point  because  the  explanations  here 
offered  afford,  as  will  be  shown  later,  a  cleiv  to  many  obscure  effects  of 
hydriatric  procedures. 

Dastre-Morat  Law  of  Antagonism. — Physiologists  have  long  recog- 
nized a  "  certain  antagonism  "  between  the  external  and  internal  vessels, 
especially  those  controlled  by  the  splanchnic. 

Increase  of  Volume  Shown  by  the  Plethysmoyraph. — By  his  original 
*Huber,  Bohm,  and  Davidoff  :  "Text-book  of  Histology. " 
f  Wiener  klinische  Wochenscbrif t,  1896,  p.  52. 


RATIONALE   OF   THE  ACTION   OF   WATER    IN   HEALTH. 


47 


FIG.  1.— Volume  Curve  of  the  Right  Arm  before  and  after  a  Hip 
Bath  of  50°  F.     (From  Winternitz.) 


and  interesting  experiments  with  the  plethysmograph,  Winternitz* 
has  demonstrated  the  hydrostatic  effect  of  hydriatric  applications.  He 
placed  a  man  into  an  empty  hip-bath  tub,  and  covered  him  with  a 
woolen  blanket,  his  left  arm  being  introduced  into  the  glass  cylinder 
of  the  instrument.  The  apparatus  and  manometer  were  filled  with 
water  of  the  body  temperature,  and  connected  with  the  registering 
apparatus.  After 
the  lapse  of  some 
time  the  tub  was 
rapidly  filled  with 
water  at  50°  F. 
The  cold  water  pro- 
duced the  usual  ef- 
fect upon  the  pulse 
and  r  e  s  p  iration. 
The  curve  produced 
(as  shown  in  Fig.  1) 
was  registered  dur- 
ing the  whole  time 
without  interrup- 
tion. It  showed  an 
even  outline  so  long  as  the  tub  was  empty.  So  soon  as  the  water 
was  poured  in,  as  shown  at  a,  the  curve  rose  perpendicularly.  The 
volume  of  the  arm  must,  therefore,  have  increased,  because  the  water 
used  must  have  been  driven  into  the  manometer.  This  effect  continued 
for  eighteen  to  twenty  seconds,  and  the  line  dropped  slightly  during 
the  following  twenty  to  thirty  seconds,  but  it  did  not  reach  the  former 

level.  The  expla- 
nation of  this  re- 
sult can  be  found 
only  in  the  local  ex- 
citation of  the  sen- 
sory nerve  endings 
by  the  cold,  and  the 
reflex  effects  thus 
aroused  in  the  sub- 
vaso-motors  of  the 
cutaneous  vessels. 

The  author  is  in- 
clined to  explain  the  narrowing  of  the  capillary  network  by  contrac- 
tion of  the  skin  muscles  under  the  direct  influence  of  cold  prevents 
afflux  of  blood  to  the  large  vascular  area.  This  is  more  a  hydrostatic 
than  a  vasomotor  action.  Hence  a  large  quantitity  of  blood  must  have 
*"Die  Hydrotherapie  auf  physiologischer  und  kliniscber  Grundlage,"  1890. 


FIG.  2.— Volume  Curve  of  the  Right  Arm  before  and  during  a 
Hip  Bath  of  110°  F.  (From  Winternitz.)  Duration,  two 
seconds. 


48          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

entered  the  remaining  vascular  areas  of  the  body,  increasing  their 
volume.  Winternitz  claims  that  in  the  cold  hip  bath  the  vessels  of 
the  abdominal  organs  are  chiefly  contracted,  and  that  the  blood  driven 
from  them  fills  other  parts  of  the  body,  including  the  arm. 

In  another  observation  on  a  man  twenty  years  of  age,  the  same  ex- 
periment was  made  with  water  at  110°  F.,  with  the  result  shown  in 
the  curve  (Fig.  2). 

This  experiment  confirmed  those  of  Schiiller,  who  found  a  brief 
contraction  of  the  cutaneous  vessels,  followed  by  their  dilatation, 
evoked  by  the  relaxing  effect  of  the  warm  water.  As  a  result,  there 
was  an  afflux  of  blood  to  the  part,  compensated  by  diminished  blood 
supply  in  other  parts,  which  was  demonstrated  by  increase  in  the 
volume  of  the  arm. 

Ottfried  Milller,  who  has  made  some  valuable  and  apparently  re- 
liable investigations  *  on  the  distribution  of  blood  under  the  influence 
of  thermic  irritants,  claims  that  these  experiments  of  Winternitz  are 
too  brief,  hence  technically  imperfect  to  separate  the  influence  on  the 
sensory  terminals  from  that  on  the  vascular  supply.  Nevertheless  he 
found  that  the  effect  of  the  thermic  excitation  of  the  peripheral  blood- 
vessels is  doubtless  a  narrowing  under  cold  and  widening  under  warm 
applications.  Mtlller  affirms  the  antagonism  of  the  inner  and  external 
vessels.  That  the  vessels  of  the  brain  and  intestines  act  inversely  he 
demonstrated  by  an  ingenious  method  of  weighing  as  well  as  by  oph- 
thalmoscopic  examinations  of  the  fundus  oculi. 

That  contradictory  statements  regarding  the  more  delicate  and  mi- 
nute effects  of  water  on  the  organism  may  be  easily  reconciled  by  judi- 
cious sifting  of  the  evidence  is  illustrated  here.  So  conscientious  an 
observer  as  Mathes  contradicts  Schiiller's  and  Mueller's  deductions  and 
cites  the  observations  of  Klapp  in  support  of  his  sceptical  attitude. 
Klapp  found  that  rabbits  which  had  been  subjected  to  an  application 
of  hot  air  to  the  abdomen,  presented  a  dilated  condition  of  the  peri- 
toneal vessels.  There  is  no  similarity  between  Schuller's  and  Klapp's 
experiments;  the  former  were  made  with  warm,  not  hot,  water  and 
the  observations  were  made  during  the  bath,  while  the  latter  were 
made  with  hot  air  f  and  after  removal  from  it.  Difference  in  technique 
results  in  different  findings  in  physiological  as  in  therapeutic  observa- 
tions. Many  contradictory  statements  on  the  latter  may  be  explained 
in  this  way. 

That  there  is  no  contradiction  involved  in  the  conclusions  of  Nau- 
mann,  Roehrig,  and  Schiiller  will  be  demonstrated  by  the  effects  of 
various  procedures.  Baths  and  other  procedures  without  mechanical 

*  Deutsches  Archiv  f.  klinische  Medizin,  1905. 

fOpitz  (Journal  f.  Exper.  Med.,  Jan.,  1906)  lias  clearly  demonstrated  this 
difference. 


RATIONALE   OF   THE  ACTION    OF   WATER   IN    HEALTH.  49 

excitation,  when  applied  to  large  portions  of  the  body,  doubtless 
have  an  hydrostatic  effect,  while  douches,  which  impinge  on  limited 
portions,  and  are  combined  with  mechanical  effects,  act  chiefly  by 
reflex  influence.  This  demonstrates  the  great  flexibility  of  water  as  a 
remedial  agent. 

BLOOD  PRESSURE. — An  important  result  of  thermic  applications  to 
the  periphery  is  obtained  in  their  effect  upon  parts  net  directly  in  con- 
tact with  them.  Since  the  impulse  conveyed  by  the  heart  to  the  blood 
stream  continues  unabated,  the  contraction  and  subsequent  dilatation 
of  the  parts  in  immediate  contact  induce  certain  changes  by  which- 
vascular  accommodation  is  accomplished. 

If  the  blood  is  driven  out  of  the  narrowed  vessels,  it  finds  entrance 
into  the  collateral  circulation.  As  a  result  we  have  collateral  hy- 
persemia  accompanied  by  increased  tension  in  the  general  circulation. 

The  application  of  cold  to  the  cutaneous  surface,  like  that  of  other 
irritants,  even  if  it  be  followed  by  dilatation  of  the  cutaneous  vessels, 
causes  an  increase  of  blood  pressure.  The  compression  of  the  arterial 
capillaries  induces  primarily  an  acceleration  of  the  blood  stream  from 
the  arteries  to  the  veins.  The  return  of  the  blood  into  the  venous 
system  must  be  accelerated  by  this  increased  vis  a  teryo.  The  deepen- 
ing of  the  respiration  which  also  results  from  the  external  impact  of 
cold,  and  which  will  be  referred  to  below,  increases  the  rapidity  of  the 
circulation  in  the  small  vessels,  and  induces  an  increased  and  accel- 
erated return  flow  of  blood  into  the  left  auricle,  a  slower  and  more 
vigorous  systole,  and  more  active  filling  of  the  arterial  system,  which 
in  the  cutaneous  arterioles  is  limited  by  the  muscular  and  elastic  fibres 
surrounding  them. 

0.  Muller*  reports  from  the  Leipsic  clinic  the  result  of  two  thou- 
sand blood-pressure  measurements,  concluding  that:  1.  The  influence 
of  all  baths,  not  in  motion,  upon  blood  pressure  is  due  to  the  ther- 
mic excitation,  which,  given  below  the  average  temperature  of 
the  cutaneous  surface,  produces  increased  blood  pressure  of  typical 
curve  during  the  entire  bath,  with  diminution  of  the  pulse  rate, 
which  is  decidedly  influenced  by  lowering  the  bath  temperature.  2. 
Baths  above  the  cutaneous  temperature,  up  to  40°  C.  (104°  F.)  produce 
at  first  a  brief  rise,  afterward  diminution  below  the  normal  pressure, 
•which  again  rises  ;  the  pulse  rate  is  diminished  until  38°  C.  (100°  F. )  is 
reached,  then  increased.  3.  Baths  above  40°  C.  increase  persistently 
the  blood  pressure,  as  do  cold  baths,  with  increase  of  pulse  rate.  Re- 
turn to  normal  blood  pressure  ensues  after  all  in  from  one-half  to  two 
hours,  frequently  reaching  a  subnormal  degree.  4.  In  baths  involv- 
ing active  motion  (half  baths  and  wave  baths)  the  mechanical  excita- 
tion exercises  the  chief  influence,  so  that  in  douches  its  action  is  para- 

*  Congress  f.  iniu-ro  Mrdizin,  1902. 
4 


50          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

mount   and  independent  of  temperature,  increasing  blood  pressure, 
which,  however,  is  not  so  enduring. 

It  is  to  be  regretted  that  this  author  omitted  to  state  the  duration 
of  the  bath,  which,  as  has  been  shown,  exerts  a  material  influence  upon 
the  immediate  and  remote  effects  of  baths.  Strassburger  *  confirms 
Miiller's  results.  His  observations  show  three  stages  in  the  blood 
pressure — rise,  fall,  and  rise.  The  colder  the  bath  the  more  pro- 
nounced was  the  initial  rise ;  the  hotter,  the  more  pronounced  was  the 
final  rise.  In  the  hot  bath  the  pressure  was  maintained,  in  the  warm 
bath  the  fall  was  deepest.  Baths  near  the  neutral  point  (90°  F.) 
appeared  to  regulate  blood  pressure.  Strassburger  regards  the  curve 
of  the  blood  pressure  in  baths  of  40°  C.  (104°  F.)  due  to  the  condition 
of  the  vascular  tonus ;  in  the  cold  bath  the  primary  rise  of  blood  press- 
ure due  to  contraction  of  the  vessels,  the  secondary  reduction  the 
result  of  dilatation  (reaction) ;  the  rise  of  pressure  at  the  close  of  the 
hot  bath,  on  the  contrary,  the  result  of  increased  cardiac  labor. 

The  sphygmograph  demonstrates  that  the  dilatation  of  the  periph- 
eral vessels  which  ensues  upon  reaction  is  not  accompanied  by  a  loss  of 
tone  and  is  not  passive.  This  is  confirmed  by  the  opposite  effect  which 
vapor  baths  produce  upon  sphygmographic  tracings.  These  show 
plainly  a  reduction  of  tone,  diminished  tension,  and  great  dicrotism. 

It  must  be  accepted  as  a  clinically  demonstrated  fact,  for  which  a 
physiological  explanation,  as  we  shall  show,  is  not  wanting,  that  cold 
enhances  the  "  tone  "  of  the  entire  circulatory  apparatus,  while  warmth 
diminishes  this  tone.  Following  the  former  there  ensues  an  increased 
flow  of  blood,  with  the  vessels  under  heightened  tension,  while  after 
warm  applications  the  vessels  are  relaxed,  their  walls  dilated,  owing 
probably,  to  a  diminution  in  their  elasticity.  That  these  must  sooner 
or  later  produce  a  hypersemia  is  evident.  It  is  important  to  distinguish 
these  physiological  differences  between  cold  and  ivarm  applications,  be- 
cause we  obtain  quite  distinct  and  differing  effects  from  hyperaemia  pro- 
duced by  heat  and  cold. 

The  subjoined  tracings  are  offered  as  a  graphic  illustration  of  the 
effect  of  cold  and  heat  upon  the  pulse  in  ordinary  conditions.!  They 
were  made  in  the  course  of  an  experiment  to  demonstrate  that  the 
effect  of  the  Nauheim  baths  depended  as  much  upon  the  temperature 
of  the  water  as  upon  the  C02  it  contained,  although  the  latter  doubt- 
less exerts  a  specific  and  very  important  action  upon  the  peripheral 
vessels  and  cardiac  action.  My  published^  observations  have  been  con- 
firmed by  the  extensive  investigations  of  Ottfried  Miller  (J.oc.  ctt.),  who 

*Deutsches  Archiv  f.  klin.  Med.,  1905,  Bd.  82. 

f  "  The  Practical  Application  of  Hydrotherapy."  Clinical  lecture  delivered 
at  the  German  Hospital,  Philadelphia,  by  Simon  Baruch,  M.D.,  "International 
Clinics,"  vol.  ii.,  seventh  series. 

$  "Hare's  System  of  Therapeutics,"  article  Mineral  Springs,  vol.  i. 


RATIONALE   OF   THE   ACTION    OF  WATER   IN   HEALTH.  51 

used  two  series  of  baths — one  series  Avith  increasing  COa  contents  and 
of  the  same  temperature,  and  another  with  increasing  temperatures  and 
decreasing  C0a  contents.  While  pulse  rate  and  blood  pressure  are 
somewhat  influenced  by  the  Nauheim  baths,  the  temperature  of  the 
latter  was  far  more  influential  than  its  chemical  ingredients. 

The  first  tracing  (Fig.  3)  is  from  a  nurse  who  had  been  smoking 
excessively  all  day  and  did  not  realize  that  he  was  in  an  abnormal 
condition.  It  represents  a  pulse  of  low  tension,  considerable  dicro- 
tism,  small  tidal  wave  showing  feeble  ventricular  contraction,  indi- 
cated by  a  slanting  and  low  up  stroke,  and  a  somewhat  obtuse  percus- 
sion wave.  Pulse,  90;  respiration,  18;  temperature,  99.4°  F.  After 

BEFORE  FULL  BATH  808-  10  M. 


JA.U8SJO  -  32.YEARS  -  P.  90  -  R.   18  -  T.  »»•* 


FIG.  3. 


being  subjected  to  a  full  bath  of  80°  there  is  a  pronounced  change  in 
this  pulse,  as  shown  in  Fig.  4.  We  find  now  an  improved  tension, 
marked  tidal  wave,  very  moderate  (normal)  dicrotism,  good  ventricular 
contraction  as  indicated  by  the  quick  vertical  up  stroke  and  acute  per- 
cussion wave.  Pulse,  72;  respiration,  21;  temperature,  98.6°  F. 


JAtf.   2,  'ST. 


TAO*8IG-82'yEAR8-AFTEirFULL»ATH«0<'-  «  M.-P.72  -fe,,j21  -  T.  98. .6 


FIG.  4. 


Fig.  5  shows  the  pulse  tracings  of  the  same  man  on  the  following 
day,  he  having  not  smoked  at  all.  Pulse,  70;  temperature,  98.4°  F. 
He  now  received  a  perspiration  bath. 


1.    TAUSSIO  •  JAN,  3.  '97..     P.   70  -  T.  98.4. 


FIG.   5. 


Fig.  6  shows  pulse  tracings  of  the  same  subject  taken  r-hile  he  was 
perspiring  in  an  air  bath  of  180°  F.  for  ten  minutes.  Pulse,  100 ;  tem- 
perature, 99.2°  F. ;  respiration,  94.  There  is  distinct  evidence  of  weak- 


52          THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 


2.    TAUSSIG- IN  HOT  AIR  BATH  180   P.  JOO  -T.  99.2.  -  R.  24. 


Fio.  6. 


ened  ventricular  contraction,  shown  by  absence  of  tidal  wave  and  ob- 
tuse percussion  wave.     He  is  now  subjected  to  a  rain  bath. 

Fig.  7  shows  pulse  tracings  of  the  same  subject,  taken  after  a  rain 


9.      TAU88IO  -JAN.  2,  '97.  AFTER  RAIN  BATH  (FOLLOWING  HOT  Al  R.BATH)  B0°-  1  M..  -  P.  72  -  T.  M.4 


FIG.  7. 

bath  (following  the  above  hot-air  bath)  of  80°  F.,  one  minute.  Pulae 
is  now  72;  temperature,  98.4°  F. 

There  is  decided  improvement  in  the  ventricular  contraction,  evi* 
denced  by  high  and  quick  up  stroke,  a  very  acute  percussion  wave,  and 
marked  tidal  wave. 

In  another  nurse,  Victor  H (Fig.  8),  the  same  result  is  shown. 

(The  blood-cell  estimate  made  with  Daland's  hsematokrit  was,  before 
the  hot-air  bath,  with  pulse  of  70  and  respiration  of  20,  4, 500, 000  red 
and  8,500  white  corpuscles).  Immediately  after  the  hot-air  bath  (ten 


BEFORE  HOT  AIR  BAT-H  -  P.  70.  R.  20L  T.  4,500,000  RED  -  8,500  WHITE  TO  C.  C. 


VICTOR  H.  -AET.  81 


Fio.  8. 


minutes)  pulse  was  8G;  respiration,  16;  temperature,  99.5°  F.  (Figs. 
8  and  9). 

After  the  jet  douche  for  h've  seconds,  following  this  hot-air  bath, 


VICTOR  H.'-  AFTER  HOT  AIR  BATH  (5  MIN.)   P.  86-  R.  18  -  T.  99. B 


Fio.  9. 


the  pulse  was  72;  respiration,   20  and  deep;  temperature,  99°  F.; 
(blood  estimate,  5,200,000  red  and  10,000  white  corpuscles). 

Surely  there  is  no  medicinal  agent  which  produces  such  changes 


RATIONALE   OF   THE  ACTION   OF   WATER   IN   HEALTH.  53 

when  administered  in  ordinary  medicinal  doses,  and  none  the  effects 
of  which  have  been  more  clearly  and  scientifically  demonstrated  than 
the  simple  experiments  made  on  healthy  individuals  with  absolutely 
harmless  water  applications  here  clearly  show. 

What  explanation  can  be  offered  for  this  difference  between  the 
effect  of  cold  and  warm  applications  ? 

There  has  been  much  disputation  over  the  apparently  contradictory 
clinical  fact  that  both  heat  and  cold  produce  hypersemia,  but  that  the 
former  is  passive,  i.e.,  accompanied  by  loss  of  "tone,"  while  the  latter 
is  active,  i.e.,  manifested  by  increased  tone.  Like  many  other  appar- 
ently contradictory  points  in  hydrotherapy,  this  dispute  is  really  based 
upon  an  erroneous  premise.  It  is  assumed  that  because  arteries  cannot 
dilate  without  loss  of  tone,  the  cutaneous  capillaries,  which  are  filled  by 
the  reaction  after  cold  procedures,  cannot  dilate  without  loss  of  "tone." 
This  argument  would  indeed  be  tenable  if  it  were  not  based  upon  erro- 
neous premises.  The  cutaneous  capillaries  do  not  depend  as  do  arteries 
upon  a  muscular  coat  for  their  tone.  It  is  an  anatomical  fact  that 
the  muscular  fibres  and  elastic  structures  within  the  skin  fulfil  all  the 
functions  of  a  muscular  coat  to  the  cutaneous  capillaries  without  being 
structurally  united  with  them.  That  this  vicarious  muscular  coat  is 
very  sensitive  to  temperature  changes  is  evidenced  by  the  contraction 
of  the  dartos  under  cold  and  its  relaxation  under  warmth.  To  speak 
of  the  "  tone  "  or  tension  (  Wandspannunrf)  of  these  cutaneous  vessels 
is  to  credit  them  with  functions  they  do  not  possess ;  for  they  derive 
their  "  tone  "  only  from  the  condition  of  the  muscular  and  elastic  web 
surrounding  them.  The  ruddy  appearance  of  the  skin  after  a  cold 
compress,  and  its  sodden  appearance  after  a  poultice,  illustrate  this 
proposition  better  than  the  most  ingenious  laboratory  experiment.  The 
"  tone  "  imparted  to  the  entire  vascular  system  by  the  application  of 
cold  to  the  cutaneous  surface,  as  shown  above,  is  due  to  the  physio- 
logic law  that  muscular  fibres  never  remain  in  a  constant  state  of  con- 
traction. So  soon  as  the  cold  is  removed,  the  cutaneous  muscular 
fibres  begin  to  resume  their  normal  status ;  the  blood,  which  has  been 
driven  out  of  the  cutaneous  vessels  by  the  constringing  action  of  cold, 
is  slowly  replaced ;  the  capillaries  are  thus  distended  as  far  as  the  re- 
sistance of  the  contracted  muscular  and  elastic  fibres  of  the  skin  per- 
mits. So  long  as  this  contracted  state  of  the  cutaneous  structures 
continues,  the  hyperaemia  remains  "tonic,"  i.e.,  is  not  accompanied 
by  relaxation.  On  the  contrary,  it  is  maintained  by  the  enhanced  car- 
diac energy  incident  to  judicious  cold  procedures. 

When  these  anatomical  and  physiological  facts  are  considered  in 
connection  Avith  the  remarkable  observations  of  Bier,  the  rationale  of 


54  THE  PRINCIPLES  AND  PRACTICE  OF   HYDROTHERAPY 

the  influence  of  cold  applications  on  the  cutaneous  circulation  becomes 
more  c,lear.  Bier  *  claims  that  this  hyperaemia  is  not  dependent  upon 
the  cardiac  action  if  it  follows  a  previous  emptying  of  the  vessel  by  a 
constricting  agent,  and  that  such  a  hypersemia  is  not  alike  in  all 
organs,  also  that  the  vessels,  or,  as  he  puts  it,  the  tissues,  constricted 
possess  the  faculty  of  selecting  arterial  in  preference  to  venous  blood, 
when  the  constriction  is  removed.  Bier  almost  suffocated  a  pig  after 
applying  an  Esmarch  bandage  to  a  leg,  and  he  found  that  on  removal 
of  the  bandage  no  blood  laden  with  C02  was  seen  ;  only  bright  blood 
issued  from  it.  He  concluded  after  numerous  experiments,  which 
have  become  the  basis  of  his  novel  and  efficient  hyperaemia  treatment, 
that  the  same  tissue  which  attracts  arterial  blood  with  avidity  defends 
itself  against  the  flow  of  venous  blood,  thus  manifesting  a  capacity 
for  selection  between  arterial  and  venous  blood.  "  Clearly  the  reactive 
hyperaemia  arises  from  great  diminution  of  resistance  in  the  small 
vessels,  as  well  as  in  all  other  tissues,  whose  elastic  tension  has  prob- 
ably been  weakened  by  the  removal  of  blood.  .  .  .  Although  this 
occurs  independent  of  the  central  nervous  system,  we  may  assume 
with  Golz  that  there  exist  ganglia  in  all  vessels,  which,  though  not 
yet  demonstrated,  may  act  both  as  paralysers  of  the  vasoconstrictors 
and  exciters  of  the  vasodilators.  Experience  would  favor  the  latter, 
for  the  so-called  reactive  hypersemia  is  among  the  most  intense 
hyperaemias  observed,  and  it  is  a  well-known  fact  that  the  most  intense 
congestions  ensue  from  excitation  of  the  vasodilator  nerves,  as  is 
noted  in  the  erector  penis,"  etc.  Bier  terms  this  self- regulation  of 
the  blood  supply  in  the  capillaries  the  llood-sense.  The  latter,  he 
claims,  has  a  function  analogous  to  the  ordinary  sense  (of  pain  espe- 
cially), viz.,  to  protect  external  parts  against  destruction,  to  readjust 
quickly  and  surely  all  possible  disturbances  produced  by  external  in- 
juries, pressure,  etc.  He  regards  the  "  blood-sense  "  in  civilized  man 
as  degenerated,  when  compared  to  that  of  primitive  man — the  African, 
or  to  undomesticated  animals.  The  vessels  not  only  resume  their 
normal  size,  but  even  are  dilated  beyond  it,  so  that  more  blood  is  re- 
ceived by  them — a  reaction  which  is  of  immense  import  because  the 
resulting  hyperaemia  is  chiefly  arterial. 

Hitter  f  confirms  Bier's  view  that  this  active  arterial  hyperaemia 
resulting  in  parts  relieved  of  artificial  anaemia  is  independent  of  sys- 
temic influences,  i.e.,  purely  local  and  therefore  a  function  of  the  cuta- 
neous vessels  proper.  Some  facts  cited  by  Bitter  are  extremely  inter- 
esting to  the  hydrotherapist.  Kitter  froze  a  spot  on  the  arm  with 
ethyl  chloride,  and  after  permitting  it  to  thaw  and  react  with  bright 
redness  (arterial  hyperaemia) — a  condition  which  Ritter  regards  physi- 

*  "  Die  Hyperaemie  als  Heilmittel." 

f  Mitthcilungen  aus  den  Grenzgebieten,  etc.,  1903. 


RATIONALE   OF   THE   ACTION   OF   WATER   IN    HEALTH.  55 

ologically  analogous  to  inflammatory  hyperaemia — he  constricted  the 
arm  above  this  spot  with  an  elastic  bandage,  as  Bier  does  iii  his 
Stauungs-hypersemie.  The  result  was  that  the  entire  arm  assumed  a 
dark  blue  hue,  but  the  thawed  spot  remained  bright  red.  Bitter  re- 
versed the  process  by  first  producing  stasis  in  the  arm,  with  cyanotic 
discoloration,  and  afterward  freezing  and  thawing  a  spot,  with  the  re- 
sult of  the  latter  becoming  bright  red  and  remaining  so  while  the  arm 
continued  bluish.  These  experiments  certainly  demonstrate  the  ca- 
pacity of  the  vessels  to  attract  arterial  blood  under  the  most  unfavor- 
able conditions  even,  and  to  defend  themselves  against  intrusion  of 
venous  blood. 

The  correctness  of  this  view  has  not  been  established,  but  the  facts 
have  been  verified  by  the  author  and  others.  Another  plausible  ex- 
planation may  be  found  in  the  physiological  fact  that  after  a  part  has 
been  suddenly  rendered  anaemic,  its  restoration  to  normal  condition  is 
hastened  by  an  increase  of  3  to  5  times  in  the  rapidity  of  its  circulation. 
!*  When  blood  is  driven  out  of  the  cutaneous  vessels  by  the  con- 
stringing  effect  of  cold  upon  the  skin  muscles,  we  have  an  imitation  of 
the  Bier  experiment  in  a  milder  form — a  thermic  instead  of  a  me- 
chanical constriction  and  subsequent  arterial  dilatation. 
1  When,  as  occurs  in  the  application  of  cold  to  a  considerable  area, 
there  is  added  to  the  vis  a  fronte  (of  Bier)  the  vis  a  tergo  aroused  by 
the  reflex  effect  of  cold  upon  the  cardiac  muscle  aided  by  the  enhance- 
ment of  vasomotor  action  arising  from  the  resistance  at  the  periphery 
above  referred  to,  only  the  most  captious  critic  would  fail  to  arrive  at 
the  conclusion  that  there  cannot  exist  a  hypersemia  of  the  arterial 
capillaries  and  probably  also  of  the  smallest  arterioles  without  loss  of 
tone.  For,  as  the  arterial  blood  flows  and  ebbs  in  rhythmic  unison* 
with  the  ventricular  contractions,  the  muscular  fibres  and  elastic 
structure  of  the  skin  must  hold  the  immense  network  of  cutaneous 
capillaries  in  their  tonic  grasp,  as  it  were,  and  thus  maintain  that  re- 
sistance at  the  periphery  which  is  essential  to  the  maintenance  of  vas- 
cular tone. 

A  judicial  and  unbiassed  review  of  these  briefly  stated  anatomical 
and  physiological  facts  brings  out  clearly  the  erroneous  premises  upon 
which  the  contention  of  those  is  based  who  would  hold  that  it  is  im- 
possible to  obtain  a  "  tonic  "  dilatation  of  the  large  vascular  supply  of 
the  skin,  because  an  increase  of  tone  in  an  artery  is  inconsistent  with 
its  dilatation.  It  has  been  shown  above  that  the  conditions  are  not 
the  same  and  that  therefore  the  contention  of  \Viiiternitz,  based  upon 
an  immense  clinical  experience,  that  cold  procedures,  judiciously  ap- 
plied, are  followed  by  an  active  hyperseinia  (tonic  dilatation)  has  an 
absolute  rational  basis. 


56  THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

Effect  of  Heat. — During  the  application  of  heat  that  may  be  toler- 
ated without  discomfort  (under  104°  F.),  the  blood-vessels  of  the  skin 
are  distended,  because  the  muscular  and  elastic  structures  of  the  skin 
are  relaxed,  as  is  evidenced  by  its  soft,  succulent,  and  sodden  aspect. 
There  is  little  if  any  previous  anaemization,  and  therefore  no  afflux  of 
arterial  blood,  as  is  the  case  after  cold  procedures  ;  the  blood  meets 
no  resistance  and  flows  passively  into  the  cutaneous  vessels  until 
they  are  turgid.  Moreover,  the  reflex  stimulation  of  the  heart  which 
follows  a  judicious  cold  application  is  here  absent,  as  is  also  the  in- 
creased supply  of  arterial  blood  to  the  muscular  structures  which 
maintain  the  "  tone  "  of  the  cutaneous  vessels.  The  dusky  hue  of  the 
skin  under  a  warm  application  would  indicate  a  preponderance  of 
venous  over  arterial  blood.  There  being  a  relaxation  of  the  cutaneous 
vessels,  the  vasomotor  tone  is  reduced  and  the  ventricular  contractions 
are  enfeebled  (passive  hypersemia),  demanding  an  increase  in  the 
number  to  compensate  for  the  loss  of  force.  The  "  tone  "  of  the  entire 
vascular  system  is  lowered.  Anaemia  of  the  brain  adds  its  damaging 
effects  as  is  evidenced  by  faintness  during  a  prolonged  bath.  The  in- 
dividual "  bleeds"  into  the  dilated  and  passive  cutaneous  vessels. 
A  bath  of  a  temperature  above  104°  F.,  on  the  other  hand,  produces  a 
primary  contraction  of  the  cutaneous  vessels,  just  as  does  a  cold  bath. 
If  the  application  be  brief,  the  blood  pressure  rises  and  the  effect  on 
the  circulation  resembles  that  of  a  cold  procedure.  The  secondary 
effect,  however,  is  quite  different.  The  slowly  cooling  skin  which 
retains  heat  for  a  considerable  time  is  relaxed  and  the  cutaneous  ves- 
sels do  no  longer  feel  the  support  of  the  muscular  fibres ;  to  this  relax- 
ation is  added  the  general  enfeeblement  due  to  the  absence  of  refresh- 
ment and  reflex  stimulation  which  is  so  pronounced  after  cold 
applications. 

II.    EFFECT  OF  HYDKIATKIC  APPLICATIONS  UPOX  THE    COMPOSITION 

OF  THE  BLOOD. 

/.  Chanyes  In  the  Corpuscular  Elements  oj  the  Blood. — The  observa- 
tions of  Professor  Winternitz  *  on  this  subject  are  of  great  interest. 
Dr.  Winternitz  investigated  the  number  and  relative  proportions  of 
red  and  white  blood  cells  in  the  blood  before  and  after  cold  applica- 
tions, and  found  that  there  is  a  considerable  change  in  their  ratio  after 
these  procedures. 

This  change  consists  in  the  fact  that  while  a  white  cell  is  accompa- 
nied by  from  four  hundred  to  eight  hundred  red  cells  before  a  cold  ap- 
*  Blatter  fur  klinische  Hydrotherapie,  February,  1893. 


RATIONALE   OF   THE   ACTION    OF   WATER   IN    HEALTH.  57 

plication,  after  such  treatment  the  number  of  white  cells  is  increased 
from  two  to  three  times.  These  observations  were  made  in  healthy  as 
well  as  in  diseased  subjects. 

These  experiments  are  not  conclusive  in  all  directions.  He  states 
that  this  increase  of  leucocytes  continues  one-half  hour  after  the  bath. 
Its  duration  could  not  be  ascertained  with  exactness,  but  in  several 
cases  it  was  observed  two  hours  later. 

Win  tern  itz  regarded  this  as  the  only  observation  of  this  kind  until 
he  learned  that  Professor  Rovighi  had  presented  the  results  of  similar 
experiments  to  the  International  Congress  at  Rome.  These  were  made 
upon  rabbits  and  men,  and  demonstrated  that  heat  diminished  the 
number  of  the  leucocytes  in  dogs  two-thirds,  and  that  cold  doubled 
their  number. 

The  diminution  in  the  size  of  the  spleen  and  the  increase  in  blood 
pressure  and  tone  of  vessels  after  cold  application  to  the  body  surface 
have  been  proven  for  some  time.  Is  it  not  possible,  asks  Winternitz, 
that  the  leucocytes  may  thus  be  driven  forth  into  the  blood  current  in 
increased  number  from  spleen  and  liver  and  bone  marrow? 

Dr.  William  Sydney  Thayer,  of  Johns  Hopkins  University  at 
Baltimore,  claims  that  these  observations  confirm  his  own  results  from 
experiments  made  upon  himself.  He  took  a  bath  of  70°  F.,  of  twenty 
minutes'  duration,  which  was  followed  by  pleasant  reaction,  without 
shivering,  the  skin  being  red  and  warm.  The  blood  cells  were  counted 
immediately  before  the  bath,  and  again  fifteen  minutes  later,  with  the 
result  of  10,333  leucocytes  before  and  12,333  after  the  bath. 

Further  investigations  were  made  by  Dr.  Alois  Strasser,*  by  request 
of  Professor  Winternitz.  The  blood  was  taken  from  individuals  before 
rising,  hence  before  taking  food,  and  again  at  different  periods  follow- 
ing the  hydriatic  procedure.  Examinations  were  made  with  care,  and 
controlled  so  as  to  exclude  error,  as  far  as  possible.  Fleischl's  haemom- 
eter  with  0.6  salt  solution  was  used  for  haemoglobin  measurement,  and 
the  Thoma-Zeiss  apparatus,  2.5  per  cent  bichromate-of- potassium  solu- 
tion for  the  red,  and  0.1  per  cent  iced  vinegar  for  the  white  corpuscles. 
The  proportion  of  dilution  of  the  blood  was  always  0.5  to  101.  The 
individuals  experimented  on  were  healthy  or  slightly  indisposed,  and 
the  countings  were  made  by  several  assistants,  and  accepted  only  when 
they  agreed.  The  result  was  (after  all  thermic  and  mechanical  pro- 
cedures acting  upon  the  whole  surface,  as  in  cold  sheet  baths,  plunges, 
half -baths,  all  kinds  of  douches,  hot-air  baths  followed  by  cold  pro- 
cedures, alternating  hot  and  cold  [Scotch]  douches,  cold  full  baths 
with  rare  exceptions)  an  increase  of  red  blood  cells  in  blood  taken  from 
the  point  of  the  finger  or  lobe  of  the  ear.  The  leucocytes,  almost  with- 

*  Blatter  ftir  klinisclie  Hydrotherapie,  November, 


58  THE   PEINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY 

out  exception,  also  increased,  as  did  the  haemoglobin.  The  maximum 
increase  of  red  blood  cells  amounted  in  fifty-six  individuals  to  1,860,000 
in  the  cubic  millimeter;  the  maximum  leucocyte  increase  was  almost 
threefold,  the  maximum  increase  of  haemoglobin  fourteen  per  cent. 
The  increase  was  not  observed  in  all  cases  immediately  after  the  pro* 
cedure;  often  the  count  was  made  an  hour  afterward.  It  was  remark- 
able that  often  an  increase  of  leucocytes  was  observed,  although  the 
red  blood  cells  had  begun  to  diminish.  Sometimes  this  increase  could 
be  observed  two  hours  later,  at  which  time,  in  most  cases,  diminution 
usually  began.  At  what  time  the  previous  condition  of  the  blood  cells 
returns  has  not  been  determined.  In  isolated  cases  observed  for  a 
long  time  it  did  not  return  at  all,  but  some  increase  of  blood  cells  re- 
mained permanent. 

Winternitz  justly  concluded  that  there  can  be  no  doubt  of  these 
changes  occurring  after  all  cold  applications  involving  the  entire  body. 
Muscular  exercise  showed  a  somewhat  similar  effect. 

After  hot-air  or  steam  baths  "  there  was  observed  a  diminution  of 
the  red  cells  in  most  cases,  later  followed  in  robust  individuals  by 
moderate  increase. 

Thermic  applications  upon  parts  of  the  body  by  cold  foot  baths, 
fan  douches  upon  the  thighs  or  knees,  and  sitz  baths  produced  a  dimi- 
nution in  red  and  white  cells  in  the  blood  taken  from  the  lobe  of  the 
ear,  while  in  the  parts  struck  by  the  cold  water  there  was  a  decided 
increase  of  both. 

That  this  increase  of  cells  cannot  be  the  result  of  recent  or  new 
formation  is  probable. 

Error  in  these  examinations  is  excluded  by  the  fact  that  the  same 
results  were  obtained  almost  constantly  in  sixty  instances.  Moreover, 
the  increase  is  too  great  to  be  fallacious — 1,800,000  red  cells  and 
1,300  leucocytes  to  each  cubic  millimetre. 

The  fact  that  the  number  of  cells  gradually  diminishes  until  the 
previous  relation  is  established  demonstrates  conclusively  that  the 
effects  are  due  to  changes  produced  in  the  circulation,  action  of  the 
heart,  tone  of  the  vessels  and  tissues.  Under  such  favorable  condi- 
tions as  cold  applications  are  known  to  bring  about,  blood  cells  are 
driven  from  organs  in  which  stasis  and  accumulation  of  red  and  white 
blood  cells  have  occurred. 

That  this  increase  in  the  cellular  elements  of  the  blood,  which  are 
the  carriers  of  oxygen  and  carbonic  oxide,  may  have  a  decided  thera- 
peutic effect  is  taught  by  these  observations.  They  clearly  explain 
the  action  of  thermic  influences  applied  to  the  surface  of  the  body. 

The  vasomotor  influence  upon  the  composition  and  physical  condi- 
tion of  the  human  blood  lias  been  made  the  subject  of  investigations 


RATIONALE   OF   THE  ACTION   OF   WATER   IN   HEALTH.  55* 

by  Knoepfelmacher.*  These  were  undertaken  in  connection  with  the 
investigations  of  Professor  Kraus  in  the  second  medical  clinic  of  the 
university,  on  the  vasomotor  factors  which  are  active  in  pyrexiaand  in 
their  influence  upon  the  blood.  Dr.  Knoepfelmacher  examined  the 
relation  of  the  blood  cells,  haemoglobin,  and  specific  gravity  resulting 
from  such  thermic  influences  applied  to  the  cutaneous  surface  as  pro- 
duce pronounced  contraction  and  dilatation  of  the  vessels. 

It  is  a  well-known  fact  that  section  of  the  spinal  cord  above  the 
origin  of  the  splanchnic  is  followed  by  very  intense  and  rapid 
changes  in  the  circulation.  Again,  in  animals  thus  treated  irritation 
of  the  cord  may  produce  contraction  of  the  dilated  vessels  and  raise 
the  blood  pressure  above  the  normal.  Section  of  the  cord  is  followed 
in  all  cases  by  decided  diminution  of  the  number  of  blood  cells ;  irrita- 
tion of  the  nerves  produces  with  the  same  promptness  an  increase  of 
twenty-five  per  cent  and  over  in  the  blood  cells.  According  to 
Cohnstein  and  Zuntz,  a  similar  effect  is  produced  upon  the  leucocytes 
and  the  red  blood  cells.  Contemporaneously  with  these  changes 
in  the  blood  cells  there  is  a  very  decided  change  in  the  calibre  of 
the  smallest  arteries  and  capillaries.  Experiments  with  vagus  irri- 
tation have  shown  that  the  change  in  the  arterial  pressure  connected 
with  these  fluctuations  is  of  relatively  slight  effect  upon  the  blood  cells. 

Grawitz  has  studied  the  various  results  obtained  from  thermic  irri- 
tants upon  the  vasomotors  with  a  view  to  ascertain  the  fluctuations 
in  the  specific  gravity  of  the  blood.  He  found  that  sudden  rapid  tem- 
perature changes  produced  by  cold  douches,  rubbings,  or  baths,  caused 
an  increase  of  the  consistence  of  the  blood,  and  that  warm  applications 
caused  a  diminution  of  the  thickness  of  the  blood.  Grawitz  believes 
that  the  contraction  of  the  vessels  produces  a  corresponding  transuda- 
tion  of  fluid  from  the  vessels  into  the  tissues,  and  thus  concentrates  the 
blood,  while  dilatation  of  the  vessels  induces  the  reverse  process. 
Especially  remarkable  is  the  equalization  of  these  fluctuations  under 
the  regulating  activity  of  the  vasomotor  centre. 

Knoepfelmacher  endeavored  to  ascertain  if  these  changes  in  the 
human  blood,  which  have  been  shown  to  be  due  to  mechanical  condi- 
tions, alter  our  present  conception  of  the  physiological  nature  of  leucocy- 
tosis. 

For  the  purpose  of  obtaining  decided  narrowing  and  dilatation  of 
the  vessels,  Knoepfelmacher  also  used  the  reflex  excitation  of  the 
vascular  nerves  by  warm  and  cold  baths.  It  had  already  been  estab- 
lished by  experiment  in  animals  that  the  cutaneous  application  of  heat 
and  cold  is  followed  on  reflex  tracts  by  changes  in  the  lumen  of  the 
vessel,  even  without  change  in  cardiac  activity.  There  are  many  draw- 
*  Wiener  klinische  Rundschau,  1894. 


60  THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

backs  in  applying  these  procedures  to  man,  but  Knoepfelniacher  has 
made  it  very  probable  by  comparative  experiments  that  the  changes 
in  blood  composition  are  at  least  not  due  to  purely  local  changes  in 
the  blood  concentration.  He  examined  the  blood  drawn  from  the 
finger  points  of  normal  individuals  (always  excluding  digestion  leu- 
cocytosis)  half  an  hour  before  the  bath,  and  again  when  relaxation 
was  pronounced  after  the  warm  bath.  The  latter  lasted  eighteen  to 
twenty  minutes,  the  water  having  a  temperature  of  96°  to  107°  F. 
The  cold  baths  were  given  from  ten  to  twelve  minutes  at  a  tempera- 
ture of  62°  to  75°.  The  red  blood  cells  were  counted  after  Thoma 
Zeiss,  the  white  after  Thoma- Lyon;  haemoglobin  by  Fleischl's  appa- 
ratus; and  the  specific  gravity  by  Hammerschlag's  method.  The 
results  of  ten  warm  and  cold  baths  seemed  to  be  fairly  constant ;  after 
the  cold  baths  the  blood  cells  rapidly  increased  in  number,  beginning  two 
minutes  after  the  bath  was  entered.  The  maximum  increase  was 
thirty  per  cent;  a  diminution  ensued  in  half  an  hour;  only  in  one  in- 
stance the  increase  continued.  The  haemoglobin  and  specific  gravity 
of  the  blood  were  in  agreement  with  this  result.  The  white  cells  gave 
different  results.  In  eight  or  ten  separate  trials  they  increased  eighty 
per  cent  more  than  the  red  blood  cells.  This  too,  was  transient;  it 
ceased  in  half  an  hour.  Very  hot  baths,  with  subsequent  perspiration, 
were  followed  by  an  increase  of  blood  cells,  and  a  relatively  greater  one 
of  leucocytes.  Warm  baths,  which  produced  a  decided  dilatation  of 
the  visible  vessels,  caused  in  seven  out  of  ten  trials  a  reduction  of  red 
cells  up  to  twenty-three  per  cent,  combined  with  reduction  of  specific 
gravity.  The  leucocytes,  on  the  contrary.,  showed  a  different  result. 
Only  in  one  observation  did  the  number  fall  more  than  the  red  cells ; 
otherwise  there  was  a  slight  diminution. 

E.  Mangranti  *  made  some  experiments  in  the  clinic  of  Professor 
Bozzole,  in  Turin,  upon  the  changes  produced  in  the  blood  cells  by 
plunge  baths  and  ice  applications.  His  object  was  to  verify  the  ex- 
periments of  Thermes,  Winternitz,  Thayer,  Rovighi,  Murri,  Pozzo, 
and  Grawitz,  because  some  of  these  seemed  incomplete.  Observations 
in  thirty-six  cases  were  made  before  and  after  application  of  water 
between  102°  and  122°,  and  between  59°  and  32°.  The  blood  was 
counted  by  the  Thoma- Zeiss  method,  the  haemoglobin  ascertained  by 
Fleischl's  apparatus,  and  verified  by  the  chromocytometer  of  Bizzen. 

Mangranti  details  the  entire  process,  and  gives  his  conclusion  as 
follows : 

a.  Tlip  largest  increase  of  red  blood  cells,  often  above  two  millions 
per  cubic  millimetre,  during  the  period  of  largest  dilatation  of  the 
Cutaneous  vessels,  followed  a  protracted  and  intense  application  of  cold 
*  Giornale  della  Reale  Accademia,  October  10,  1895. 


RATIONALE  OF   THE   ACTION   OF   WATER   IN   HEALTH.  61 

as  well  as  of  heat,  two  opposing  factors  which  closely  unite  in  their 
final  effect  of  congestion  and  stasis,  b.  Reliable  increase  of  erythro- 
cytes  during  the  period  of  vascular  contraction  ensued  from  applica- 
tion of  cold.  c.  Diminution  of  erythrocytes,  about  one  million  to  the 
cubic  millimetre,  ensued  after  brief  application  of  heat.  d.  The  leu- 
cocytes shared  the  fate  of  the  red  cells  only  to  a  certain  extent,  e.  In 
many  instances  a  diminution  of  haemoglobin  was  found  which  did  not 
correspond  with  the  increase  of  the  red  blood  cells. 

The  difference  in  the  findings  of  Knoepfelmacher  and  Mangranti 
is  easily  accounted  for  by  the  difference  in  technique.  Mangranti 
does  not  state  the  duration  of  his  "  protracted  baths."  They  were 
doubtless  very  brief,  because  individuals  who  could  bear  a  protracted 
bath  of  102°  to  122°  and  from  32°  (?)  to  59°  F.  do  not  exist. 

Mangranti's  results — increase  of  red  blood  cells,  after  hot  as  well  as 
after  cold  applications,  and  the  diminution  of  these  cells  after  brief  ap- 
plication of  heat — prove  conclusively  that  both  heat  and  cold  act  as 
irritants,  but  that,  the  effect  of  heat  being  due  to  a  relaxation  of  the 
muscular  and  elastic  fibres  which  form  a  substitute  for  the  muscular 
coat  of  larger  vessels  and  a  decrease  in  cardiac  force,  this  fulness  of  the 
vessels  ceases  after  brief  applications;  while,  the  plethora  of  the  vessels 
resulting  from  cold  applications,  being  due  to  a  combination  of  Bier's 
arterial  selection  process,  with  increased  vis  a  teryo  from  the  heart,  as 
explained  above,  a  reaction  ensues  which  maintains  the  tone  of  the 
vessels  and  fills  them  with  arterial  blood  chiefly. 

//.  Changes  Produced  in  the  Density  of  the  Blood. — Dr.  Burton- 
Opitz  reports  from  the  Physiological  Laboratory  of  Columbia  Uni- 
versity *  the  result  of  six  experiments  on  dogs  which  he  subjected  to 
baths  of  43°  C.  (109.4°  F.)  and  23°  C.  (73.4°  F.)  to  test  the  viscosity 
of  the  blood  under  such  baths.  The  carotids  were  free,  the  animals 
secured  in  the  tub  under  light  ether  narcosis.  He  claims  that  it  is 
conclusively  proved  that  the  viscosity  was  sharply  increased  by  the 
cold  bath  and  decreased  by  the  warm  bath  ;  the  specific  gravity  run- 
ning a  parallel  course.  The  tables  shown  on  page  62  record  two  of 
these  experiments. 

Since  Burton-Opitz  does  not  offer  a  rationale  of  this  process  in  this 
essay,  I  have  sought  to  obtain  an  explanation  from  the  experiments  of 
Loewy  who  exposed  rabbits  in  a  roomy  box  to  a  temperature  of  near 
100°  F.  for  twenty-four  hours,  f  "The  blood  taken  from  the  large 
vessels  of  the  ears  became  more  watery  than  is  normal,  despite  the 
fact  that  evaporation  by  perspiration  was  great.  The  blood  became 
thinner." 

*  Journal  of  Experimental  Medicine,  January,  1906. 
\  Berliner  klinische  Wochenschrift,  No.  41,  1896. 


62 


THE   PRINCIPLES   AND   PRACTICE   OF    HYDROTHERAPY. 


THE  EFFECT  OF  WAKM  WATER  BATHS. 


Number  of  Ex- 
periment and 
Weight  of  Dog. 

Determination 
Number. 

Tempera- 
ture °  C. 

Time  Elapsed 
since  beginning 
of  Bath.  Min. 

Specific  Gravity 
of  the  Blood. 

Quantity  Fscaped 
from  C'apiilary- 
Tube.  Mgr. 

F 

$  . 

Viscosity  Co- 
efficient, 
K. 

JS 

§0 
0> 

i 

Greatest 
Difference. 

of  water. 

of  animal, 
rectal. 

*1      f  Normal..  -< 

A&] 
KSO  |  During       I 
w     (.Bath  1 

1 
2 
3 

- 

37^.5 

37.2 

- 

1.0500 

2004.2 
1782.1 
1663.1 

13.28 
11.89 
12.32 

151.90 
149.60 
137.50 

1039.32 
1048.00 
1026  95 

1  1038.09 
i  1134.11 

1-101.39 

4 
5 
6 

42.0 

39.8 

15 
30 
45 

1.04832 

1782  9 
1768  9 
2038  7 

10.39 
10.78 
12.26 

159.60 
151.30 
152.90 

1126.48 
1136.38 
1139.48 

THE  EFFECT  OF  COLD  WATER  BATHS. 


| 

1 

_ 

37  0 

1.05236 

1387.7 

12  90 

113.30 

976  70 

1 

,j      f  Normal  .  .  - 

2 

— 

— 

1742.1 

13.62 

136.50 

978  01 

V   978.02 

1 

"  si                      ' 

8 

_ 

37.0 

— 

' 

1871.7 

13.92 

143.30 

979.36 

r 

1 

•  —  1 

}•  129.  17 

K"*1  I                   ' 

4 

22.0 



15 

1.05375 

1761.9 

14  20 

135.60 

953  80 

K        During      \ 
iBath....  < 

5 
6 

— 

30 
45 

2025.7 
2382  6 

17.17 
17.61 

136.0(1 
159.10 

904.22 
886.41 

898.32 

f 

7 

33.5 

60 

1198.3 

11.17 

131.70 

848  a5 

The  body  must  have  become  poorer  in  water.  In  order  to  render 
this  positive  of  proof,  the  quantity  of  water  in  the  muscles  was  ascer- 
tained. In  the  majority  of  these  experiments  the  muscles  proved  to 
be  poorer  in  water,  which  Loewy  regarded  as  due  to  the  general  re- 
moval of  water  from  all  the  tissues.  The  plasma  of  the  blood  proved 
to  be  increased.  Warmth  produces  a  widening  of  a  large  area  of  the 
circulatory  system;  the  resistance  offered  to  the  movement  of  the 
blood,  and  consequently  the  blood  pressure,  is  diminished.  Thus  a 
diminished  transudation  of  plasma  into  the  tissue  and  lymph  spaces  is 
brought  about,  resulting  in  an  increase  of  the  plasma  in  the  blood. 
This,  however,  may  not  entirely  explain  it,  because,  although  enlarge- 
ment of  the  vessels  causes  a  reduction  of  pressure  in  the  smallest  arte- 
ries, it  does  not  necessarily  follow  that  the  pressure  in  the  capillaries 
is  also  reduced,  as  is  shown  by  Heidenhain  and  others.  The  extent 
of  transudation  of  the  blood  plasma  depends  mostly  upon  pressure  in 
the  capillaries.  Moreover,  it  may  be  that  inasmuch  as  heat  induces  a 
greater  giving  off  of  water,  chiefly  from  the  lungs,  this  diminution  of 
water  reaches  the  arterial  system,  and  the  capillaries  become  poorer  in 
water.  Thus  osmotic  equalization  processes  may  ensue,  by  reason  of 
which  fluid  may  transude  from  the  lymph  and  tissue  juices  into  the 
blood-vessels.  But  these  osmotic  processes,  be  they  ever  so  extensive, 
cannot  alone  produce  a  thinning  of  the  blood. 

Since  this  thinning  of  the  blood  may  not  thus  be  absolutely  proved, 


RATIONALE   OF   THE   ACTION   OF   WATER   IN   HEALTH.  63 

Loewy  offers  other  evidence  to  demonstrate  it.  Eight  rabbits 
were  kept  from  one-half  hour  to  fifteen  minutes  in  a  box  whose  tempera- 
ture was  between  148°  and  150°.  In  each  one  there  was  a  pronounced, 
often  a  very  considerable,  reduction  of  the  density  of  the  blood,  which 
was  quite  as  decided  as  after  a  retention  for  twenty -four  hours  in  a 
box  with  a  temperature  of  86°  to  91°.  No  difference  in  effect  was 
perceptible  between  a  warming  of  two  hours  and  one  of  fifteen 
minutes.  The  number  of  red  cells  was  diminished.  The  density  of 
the  serum  was  unchanged  in  these  experiments.  Hence  the  Influence 
of  even  very  brief  exposure  to  heat  upon  the  composition  of  the  circulat- 
ing blood  appears  to  be  very  considerable.  What  processes  account  for 
these  changes?  There  cannot  be  an  absolute  change  in  the  quantity 
of  corpuscular  elements  or  of  the  plasma ;  the  former  cannot  be  abso- 
lutely diminished,  and  the  latter  cannot,  in  the  brief  time  of  the  ex- 
periment, be  so  considerably  increased.  We  must,  therefore,  accept 
these  changes  as  occurring  in  the  relative  proportion  of  corpuscular 
elements  and  of  water  of  the  blood.  Moreover,  in  these  brief  trials 
there  cannot  occur  sufficient  evaporation  of  water  to  increase  the  vis- 
cidity of  the  blood.  No  considerable  stream  of  fluid  can  be  made  to 
flow  by  osmosis  from  the  tissues  into  the  capillaries;  certainly  not 
enough  to  increase  the  blood  plasma.  If  this  were  the  case  even,  it 
would  not  explain  the  impoverishment  of  the  blood.  Such  osmotic 
processes  have  been  shown  by  Cohnstein  and  Zuntz  to  occur  very 
slowly ;  too  slowly  to  accomplish  the  above  purposes. 

Loewy  believes  that  the  blood-thinning  process  may  be  best  ex- 
plained as  follows :  By  reason  of  the  increase  of  large  areas  of  the 
capillary  system,  arising  from  dilatation  of  cutaneous  vessels,  a  greater 
amount  of  corpuscular  elements  enters  vessels  which  previously  have 
been  filled  only  with  plasma  (the  vasa  serosa)  or  which  afforded  room 
only  for  a  small  number  of  corpuscles.  Those  corpuscles  only  were 
withdrawn  in  large  number  from  the  larger  vessels,  the  blood  of  which 
was  used  for  the  experiment;  the  blood  thus  lost  formed  elements; 
its  density  was  diminished.  The  plasma  displayed  no  change. 

That  changes  in  the  tone  of  the  vessels  may  produce  such  consider- 
able and  rapid  changes  in  the  composition  of  the  blood  as  were  shown 
by  Loewy's  experiments  of  a  few  minutes'  duration,  has  been  dis- 
tinctly proven  by  the  experiments  of  Cohnsteiu  and  Zuntz. 

They  found  that  the  corpuscular  contents  of  the  larger  blood-vessels 
depend  upon  the  capillaries  and  upon  the  quantity  of  blood  circulating 
in  them ;  that  conditions  that  narrow  their  luniina  increase  the  corpuscles 
in  the  blood-vessels ;  and,  reversely,  that  those  conditions  which  dilate 
the  capillaries  produce  a  diminution  of  the  blood  corpuscles  in  the 
blood-vessels.  For  example,  this  effect  is  produced  after  section  of 
the  spinal  cord,  during  venous  stasis  and  during  muscular  activity. 


64          THE   PRINCIPLES   AND   PRACTICE   OF    HYDROTHERAPY. 

Schoeuburg  and  Zuntz  ascribe  the  changes  in  the  blood  produced  by 
high  altitudes  to  changes  in  the  tone  of  the  blood-vessels,  and  the 
remarkable  change  produced  by  light  upon  the  composition  of  the 
blood,  as  discovered  by  Fuller  in  Zuntz' s  laboratory,  may  also  be  at- 
tributed to  the  same  cause. 

All  these  factors  are  also  connected  with  heat,  which,  in  the  same 
manner  and  with  the  same  rapidity,  induces  a  diminution  of  the  cor- 
puscular elements  in  the  large  vessels,  and  thus  in  the  specific  gravity 
of  the  blood. 

There  are  many  other  investigations  reported  on  the  influence  of 
thermic  agencies  upon  blood  composition,  and  they  all  refer  to  brief 
applications.  Winternitz  *  reports  that -cold  always  concentrates  the 
blood,  which  is  condensed  by  increase  of  the  number  of  red  blood  cells, 
while  warmth  produces  in  the  majority  of  instances  their  diminution. 

Knoepfelmacher  f  noted  the  same  results.  All  three  of  these  ob- 
servers have  always  investigated  the  total  blood  in  one  part  of  the  body. 
Despite  the  agreement  in  the  results,  their  significance  differs.  All  three 
of  these  authors  ascribe  them  to  the  influence  exerted  by  thermic  agencies 
upon  the  muscular  structure  of  the  vessels — contraction  of  large  seg- 
ments of  vessels  by  cold,  relaxation  by  heat.  Winternitz  and  Knoepfel- 
macher explain  them  by  the  theory  that  changes  in  the  dimension  of  the 
vessels  (besides  changes  in  the  circulation)  produce  changes  of  the  cor- 
puscular elements,  without  regard  to  any  changes  in  the  fluidity  of  the 
blood.  Winternitz  further  insists  that  the  increase  in  the  number  of 
the  corpuscular  elements  under  the  influence  of  cold  is  due  to  the  fact 
that  large  masses  of  blood  cells  are  driven  into  the  general  circulation 
from  organs  in  which  stasis  or  other  accumulation  of  blood  has  taken 
place.  In  opposition  to  this  view,  Grawitz  has  repeatedly  insisted 
that  these  results  are  due  not  to  the  condition  of  the  corpuscular  ele- 
ments, but  to  that  of  the  blood  serum,  inasmuch  as  the  irritation  of 
the  vasomotors  by  cold  and  the  resultant  heightened  blood  pressure  in- 
duce a  transudation  of  water  from  the  blood  into  the  tissues,  and  thus 
the  blood  becomes  more  concentrated,  the  reverse  being  the  case  under 
warmth,  which  brings  about  a  diminution  of  blood  pressure  and  thus 
draws  the  water  from  the  tissues  into  the  vessels,  inducing  a  thinning 
of  the  blood.  This  view  cannot  be  accepted  even  under  Cohnstein  and 
Zuntz' s  observations,  and  Loewy's  investigations  in  the  density  of 
the  serum  contradict  it.  He  therefore  agrees  with  Winternitz  and 
Knoepfelmacher,  who  consider  the  chief  agency  in  changing  the 
density  of  the  blood  to  be  a  changed  distribution  of  corpuscular  ele- 
ments in  the  vascular  system.  That  Winternitz' s  view  that  the  inner 
organs  take  part  in  the  process  as  well  as  the  vessels  of  the  skin  is 

*  Centralblatt  fur  innere  Medicin,  1893. 
f  Wiener  klinische  Wochenschrift,  1893. 


RATIONALE   OF   THE   ACTION   OF   WATER   IN   HEALTH.  65 

correct  seeins  to  be  demonstrated  by  Breitenstein's  investigation, 
which  follows  below.  Loewy  hopes  to  show  by  the  publication  of  the 
results  of  these  investigations  the  practical  importance  of  those  of 
Cohnstein  and  Zuntz,  which  have  not  been  sufficiently  recognized,  but 
at  the  same  time  he  emphasizes  that  for  the  purpose  of  clearing  up  the 
problems  presented  by  the  examination  of  the  blood  we  should  not 
limit  ourselves  to  the  determination  of  the  relation  of  the  blood  at 
one  or  more  points  placed  under  the  same  conditions.  In  order  to 
deduce  conclusions  of  a  general  nature,  we  should,  like  Breitenstein, 
examine  the  blood  of  several  vascular  provinces,  whose  circulatory  con- 
ditions are  different,  or  we  should  examine,  besides  the  total  blood,  at 
least  one  of  the  constituents,  since  the  blood  consists  of  water  and 
cells. 

Breitenstein  *  has  published  some  observations  which  throw  much 
light  upon  this  interesting  subject.  He  obtained  the  blood  from 
healthy  and  sick  individuals  by  a  small  incision  into  the  lobe  of  the 
ear,  gathering  it  without  pressure.  The  individual  lay  on  a  sofa 
in  an  empty  room,  with  body  slightly  elevated.  After  a  rest  of  one- 
quarter  of  an  hour  the  blood  was  obtained  and  examined  with  the 
most  modern  appliances.  A  bath  of  77°  F.,  of  ten  minutes'  duration, 
was  now  applied,  after  which  the  individual  again  rested.  The  subjects 
were  eleven  healthy  men  and  three  chlorotic  girls.  In  eight  of  these 
an  increase  of  red  blood  cells  was  noted,  in  three  an  insignificant 
diminution,  two  of  the  latter  being  chlorotic  girls.  Thus  was  demon- 
strated the  fact  that  cool  baths  produced  an  increase  of  red  blood 
cells  in  the  peripheral  vessels.  "Wintemitz  had  observed  the  same 
results,  but  these  were  from  hydriatric  procedures  which  produced 
energetic  reaction  in  the  skin.  Breitenstein  concludes  that  the 
slight  reduction  of  the  temperature  plays  no  role,  because  in  his  ex- 
periments there  was  no  relation  to  be  noted  between  the  lowering  of 
the  temperature  and  the  increase  of  blood  cells.  This  was  confirmed 
by  experiments  with  antipyrin,  in  which  the  largest  temperature  re- 
duction was  not  always  accompanied  by  the  largest  effect  upon  the  red 
cells.  Neither  reduction  of  temperature,  nor  of  respiration,  nor  of 
pulse  furnishes  any  clew  to  the  change  in  the  corpuscles.  New  forma- 
tion of  the  latter  cannot  be  claimed,  it  being  impossible  that  so  large 
a  number  could  be  formed  within  an  hour.  According  to  Breitenstein, 
a  change  in  the  plasma,  as  argued  by  Grawitz,  is  scarcely  to  be 
thought  of,  because  it  is  a  well-known  fact  that  it  is  very  difficult  to 
change  the  normal  composition  of  the  blood  for  any  length  of  time. 
Where  did  these  blood  cells  remain  hidden?  They  could  not  be  de- 
stroyed any  more  than  they  are  destroyed  in  febrile  conditions.  There 

*Archiv  fur  experimentelle  Pathologie  und  Pharmakologie,  Bd.  32,  1896. 

5 


66 


THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 


is  no  ground  for  claiming  that  the  blood  is  thinned.  They  must  have 
become  lodged  somewhere.  Breitenstein  sought  for  them  in  the  liver, 
by  taking  the  blood  from  the  latter  and  from  the  ear  at  the  same  time, 
under  all  necessary  precautions  with  regard  to  agitation,  eating,  etc., 
before  and  after  the  heating  process.  The  blood  cells  were  found  to 
be  equal  in  the  ear  and  liver  before  the  animals  were  subjected  to  the 
heating  process ;  but  after  the  latter  there  was  an  enormous  increase  of 
red  blood  cells  in  the  liver,  as  is  graphically  shown  in  the  following 

table. 

EXPERIMENTS  BY  OVERHEATING  THREE  RABBITS. 


No. 

Weight  in  Grams. 

Temp,  of 
Kectum. 

Number  of 
Red  Blood  Cells 
in  Millions. 

Difference 
Between  Blood 
from  Veins 
of  the 
Ear  and  Liver. 

Haemoglobin 
Per  Cent 
Values. 

I 

2  120 

39.  0°  C. 

Ear,      5,992 

11  84 

Temp,  of  hot  box, 
28-33°  R 

Liver,  5,840 
Ear,      5,132 

-152,000 

12.12 
10.72 

TT 

2,250 

1,880 

40.3 
38.9 

Liver,  6,250 
Ear,      5,720 

+  938,000 

12.12 
12.40 

Temp,  of  hot  box, 
28-30°  R. 

Liver,  5,896 
Ear,      5,996 

+  176,000 

12.84 
11.22 

in 

1,900 
2  370 

40.5 
39.3 

Liver,  6,204 
Ear,      5,440 

+  908,000 

13.28 
11.00 

Temp,  of  hot  box, 
30-36°  R. 

Liver,  5,584 
Ear,      5,320 

+  144,000 

11.32 
11.32 

2,150 

43.3 

Liver,  6,112 

+  792,000 

12.40 

In  Professor  Gerhardt's  clinic  this  subject  was  studied  by  Becker.* 
The  latter  is  disposed  to  dissent  from  all  other  authorities,  not  in  the 
actual  results  however,  but  in  their  explanation.  He  concludes  (p. 
182) :  1.  An  application  of  cold  to  the  entire  body  produces  a 
smaller  increase  of  erythrocytes  than  of  leucocytes  in  the  blood  of  the 
cutaneous  capillaries.  2.  These  changes  are  due  mostly  to  vasomotor 
influences,  chiefly  the  loss  of  water  from  the  blood,  and  less  to  a  stasis 
of  the  blood  cells  in  the  capillaries.  3.  An  increase  of  leucocytes 
ensues,  besides,  and  for  the  greatest  part  through  the  formation  of 
layers  in  the  margins  of  the  blood-stream,  after  cold.  4.  In  pathologic 
conditions  changes  in  the  composition  of  the  blood  may  also  be  ex- 
plained by  the  moderate  diminution  of  stases. 

E.  Tschlenoff  t  subjected  six  rabbits  to  a  hot-air  chamber  of  42° 
C.  (107.6°  F.)  for  five  to  six  hours  and  found  a  loss  of  fifty  per  cent,  in 
the  leucocytes  and  no  change  in  the  haemoglobin  and  red  cells.  This 
loss  was  compensated  in  twenty  hours. 

Changes  in  the  renal  circulation  have  been  observed  by  Rem-Piceit 

*  Blatter  f.  klin.  Hydrotherapie,  August,  1902,  No.  8. 
fWratech,  9  and  10,  1893. 
\  II  Policlinico,  1901,  No.  53. 


RATIONALE   OF   THE  ACTION    OF   WATER   IN    HEALTH.  67 

who  made  one  hundred  and  fifteen  experiments  on  thirty-five  healthy 
persons,  with  three  hundred  and  fifty  urinary  analyses.  He  found 
that  albumin  is  found  with  considerable  regularity  after  cold  baths 
(12°  to  13°  C.  for  three  minutes) ;  baths  of  fifteen  minutes  of  20° 
produce  the  same  effect.  The  albumin  appears  quickly,  but  lasts  only 
a  few  hours,  never  exceeds  one-quarter  of  one  per  cent.,  and  is 
mostly  serum  albumin,  never  nucleo-albumin ;  not  rarely  hyaline  casts 
and  crystals  of  oxalate  of  lime  were  observed.  Frequently,  though 
not  always,  there  was  increased  diuresis,  especially  after  short,  very 
cold  baths  in  the  open  air.  Relatively  larger  quantities  of  solid  urinary 
constituents  are  excreted.  Nitrogen  and  urea  and  chlorides  are  in- 
creased; there  was  no  urobilin.  After  short  cold  baths  and  douches, 
blood  pressure  was  increased;  after  long  and  very  cold  baths,  a  more 
rapid  and  irregular  heart  action,  more  or  less  diffused  cyanosis,  and 
manifest  dilatation  of  the  right  ventricle.  Rein-Picei  holds  that  al- 
buminuria  following  cold  baths  depends  upon  the  cutaneous  excita- 
tion, which,  affecting  the  peripheral  sensory  endings,  is  conveyed 
to  the  central  nervous  system,  and  reflected  upon  the  route  of  the  vagus 
or  sympathetic;  this  is  evident  from  the  fact  that  injuries  of  the  vagus 
also  produce  albuminuria. 

Confirmation  of  these  findings  may  be  found  in  Strasser  and  Wolf's 
experiments  with  the  onkorneter.*  ,  • 

Intense  cooling  of  the  skin  produces  changes  in  the  renal  circula- 
tion. The  latter  is  never  produced  by  the  usual  hydriatric  procedures, 
because  they  are  never  applied  so  cold,  without  adding  friction,  which 
counteracts  the  congesting  effect  of  cold  upon  the  internal  organs. 
Experiments  like  the  above  go  to  show  that  the  charge  made  by  Adler  * 
and  a  few  others,  that  laboratory  experiments,  such  as  we  have  on 
strychnine  and  other  medicinal  agents,  are  wanting  in  hydrotherapy, 
is  unfounded  in  fact. 


EXPERIMENTS  TO  ASCERTAIN  THE  EFFECT  OF  VARIOUS.  PROCEDURES 
UPON  THE  BLOOD  CONSTITUENTS  IN  HEALTH  AND  DISEASE. 

With  a  view  to  test  the  influence  of  various  procedures  in  health 
and  disease  I  instituted  some  experiments  in  the  Hydriatric  Institute, 
in  which  I  was  assisted  by  my  son,  Dr.  H.  B.  Baruch,  and  in  the 
Montefiore  Home,  which  were  conducted  under  my  direction  by  Dr. 
Abramson,  assisted  by  Dr.  Talmey.  The  counts  were  made  just  before 
and  within  fifteen  minutes  after  each  procedure;  with  Deland's  hsema- 
tokrit  in  the  Hydriatric  Institute,  and  with  the  Thoma-Zeiss  apparatus 
in  the  Montefiore  Home. 

*B1.  f.  klin.  Hydroth.,  1903. 

t  New-Yorker  mcdiz.  Monatsschrift.  1897. 


68 


THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 


In  Hydriatric  Institute. 


Name. 

c 
«>c 

<J 

Condition 
and 
Procedure. 

Red  Cells, 
Number  to  Cubic 
Millimetre. 

White  Cells, 
Number  to  Cubic 
Millimetre. 

Before. 

After. 

Before. 

After. 

Victor  H. 
(masseur). 

Same  

31 

31 
32 

Healthy  ;  hot- 
air  bath. 
Followed    by 
jet  douche, 
at  80°  F.,  5 
sec. 
Healthy  ;    jet 
douche,  80° 
F.,  10  sec. 
Healthy  ;  full 
bath,  80°F., 
10  min. 

4,500,000 

4,500,000 
5,000,000 

5,800,000 

5,200,000 
5,800,000 

8,500 

8,500 
9,000 

10,500 

10,000 
10,500 

Blood   from 
lobe  of  right 
ear   meas- 
ured with 
Deland  'a 
haematocrit. 
do. 

do. 

T  

(doucheur) 

In  Montefiore  Home. 


Name.  " 

a? 
60 
< 

Disease 
and  Procedure. 

Red  Cells- 
Number  to  Cubic 
Millimetre. 

White  Cells- 
Number  to  Cubic 
Millimetre. 

Per  Cent, 
of  Haemc. 
globin. 

Before. 

After. 

Before. 

After. 

Be- 
fore. 

Af- 
ter. 

William 

24 

Paralysis  agitans  ; 

6,491,666 

5,444,444 

6,000 

11,600 

120 

TlO 

H. 

full  bath,  95°  F., 

30  min. 

Bertha  D. 

67 

Paralysis  agitans  ; 

4,250,000 

5,666,666 

5,100 

5,200 

105 

103 

full  bath,  95°  F., 

30  min. 

Nanette  G. 

Basedow's     d  i  s- 

4,875,000 

4,091,666 

5,131 

11,400 

75 

90 

ease  ;  wet  pack, 

60°  F.,  Ihour. 

Matilda  G. 

16 

Phthisis      pulmo- 

4,833,000 

4,933,355 

8,000 

10,400 

76 

75 

nalis  ;  h  o  t  -  a  i  r 

bath  until  warm, 

followed  by  rain 

bath,    60°  F.,    30 

Ibs.  pr.  1  min. 

Mollie  M. 

58 

Chronic   nephri- 

2,166,666 

3,055,555 

9,500 

10,400 

50 

45 

tis  ;  hot-air  bath. 

Augusta 

31 

Arthritis       defor- 

4,450,000 

4,980,335 

6,400 

9,400 

80 

80 

P. 

mans  ;  perspired 

in  a  hot-air  bath 

10  min. 

Jenny  L. 

21 

Hysteria  ;      rain 

3,718,752 

4,125,000 

6,800 

8,200 

70 

90 

bath,    60°  F.,  30 

Ibs.  pr.  1  min. 

Lena  D. 

12 

Chronic    bronchi- 

5,325,000 

5,590,000 

7,500 

10,500 

75 

90 

tis  ;    rain   bath. 

80°  F.  ,  30  Ibs.  pr, 

1  min. 

RATIONALE   OF  THE  ACTION  OF  WATER   IN   HEALTH.  69 

In  Montefiore  Home. — Continued. 


Name. 

-' 
be 

< 

Disease  and 
Procedure. 

Red  Cells, 
Number  to  Cubic 
Millimetre. 

White  Cells, 
Number  to  Cubic 
Millimetre. 

Per  Cent 
of  Haemo- 
globin. 

Before. 

After. 

Before. 

After. 

Be- 
fore. 

Af- 
ter. 

Annie  8. 

9 

Rickets  ;    circular 

3,321,666 

3,575,000 

7.5001 

11,000 

83 

80 

(needle)  bath,  60° 

F.,  15  Ibs.  pr.  1 

min. 

Lizzie  B. 

30 

Chronic  gastritis  ; 

4,112,500 

5,366,666 

8,000 

8,000 

90 

95 

circular  bath,  80° 

F.,   15  Ibs.  pr.  1 

min. 

Nathan  B. 

28 

Neurasthenia  ;  jet 

4,525,000 

5,683,333 

8,600 

8,600 

100 

105 

douche,    60°   F., 

15  Ibs.  pr.  20  sec. 

Julius  D. 

38 

Friedreich's  atax- 

4,691,666 

5,375,000 

9,600 

8,600 

105 

105 

ia  ;    jet  douche, 

80°   F.,    15    Ibs. 

pr.  20  sec. 

Joseph  B. 

40 

Dilatatio  ven  t  r  i  - 

4,133,333 

4,658,333 

8,200 

8,200 

100 

100 

culi     et   neuras- 

thenia;     jet 

douche,    45°   F., 

15  Ibs.  pr.  10  sec. 

EosaG. 

42 

Locomotor  a  t  a  x  - 

4,683,300 

4,641,000 

14,375 

9,400 

100 

95 

ia  ;   jet   douche, 

95°  F.,  30  Ibs.  pr. 

20  sec. 

Minnie  G. 

44 

Multiple  sclerosis  ; 

4,783,300 

4,958,333 

5,419 

6,800 

85 

85 

jet    douche,    95° 

F.,    30    Ibs.    pr. 

20  sec. 

Lillie  F. 

29 

Tabes  ;  jet  douche  ; 

5,262,000 

4,216,666 

4,500 

8,400 

80 

90 

110°  F.,    20  Ibs. 

pr.  30  sec. 

CHANGES  IN  THE  CHEMICAL  CONSTITUENTS  OF  THE  BLOOD. 

Alois  Strasser  has  undertaken  to  study  the  chemical  reaction  of  the 
blood  under  thermic  applications.  The  experiments  made  upon  him- 
self and  Dr.  Kuthy  are  detailed  in  the  Deutsche  Medizinal-Zeituny, 
June  loth,  1896.  The  results  are  briefly  summarized  as  follows :  After 
all  warm  or  hot  hydriatic  procedures  (chiefly  baths  of  about  110°  F. ), 
an  increase  of  the  relative  quantity  of  acid  phosphate  was  invariably 
noticed;  most  often  it  was  considerable  (once  over  one  hundred  per 
cent). 

After  cold  procedures  the  relative  quantity  of  acid  phosphate  was 
diminished,  the  greatest  diminution  Avas  after  half-baths  (about  fifty 
per  cent);  small  diminution  followed  the  douche,  cold  sheet,  or 


70          THE   PRINCIPLES   AND   PRACTICE   OF    HYDROTHERAPY. 

plunge  in  a  bath  of  about  48°  F.  The  blood  was  taken  under  anaes- 
thesia from  one  femoral  artery  before  and  from  the  other  after  the  ex- 
periment. The  result  showed  a  diminution  of  blood  alkalinity  after 
hot  baths,  and  an  increased  alkalinity  of  the  blood  after  cold  baths. 

Pokrowsky*  demonstrated  by  his  experiments  that  the  assimilation, 
of  nitrogen-containing  foods  is  increased  by  hot-air  baths,  the  quantity 
of  faeces  and  of  nitrogen  contained  in  it  is  diminished,  and  the  body 
weight  is  increased  (?). 

Gussero  f  claims  also  an  enhancement  of  nitrogen  change  after  hot 
baths. 

CHANGES  IN  THE  LYMPH  MOVEMENT. 

A  series  of  carefully  conducted  laboratory  experiments  was  con- 
ducted by  E.  von  Kowalski  $  in  the  physiological  laboratory  of  Pro- 
fessor Beck,  of  the  Leuibert  University,  for  the  purpose  of  ascertaining 
the  influence  of  thermic  irritants  upon  the  movement  of  lymph  and 
upon  the  vasomotor  nerves  of  the  lymph  vessels.  Without  entering 
upon  the  interesting  details  and  comments  of  the  author,  the  following 
conclusions  are  of  interest:  1.  Thermic  irritants  exercise  an  influence 
upon  the  flow  of  lymph  not  only  indirectly  by  reason  of  the  simultane- 
ous changes  in  the  other  organs,  but  also  by  changing  the  calibre  of 
the  lymph  vessels;  thermic  irritants  of  low  temperature  contract  these 
vessels,  higher  temperatures  dilate  them.  2.  The  reason  for  these 
changes  may  be  found  in  the  nervous  system,  because  the  lymph  ves- 
sels are  subject  to  the  same  influences  as  the  blood-vessels — viz., 
from  vasomotor  nerves,  which  produce,  when  excited  by  low  tempera- 
ture, contraction,  and  when  excited  by  high  temperature  evoke  dilata- 
tion. 3.  The  vasomotor  nerves  of  the  lymph  vessels  are  not  identical 
with  the  corresponding  nerves  of  the  blood-vessels ;  at  any  rate,  their 
activity  is  independent  of  the  circulation. 

Practically,  we  obtain  from  these  facts  some  clew  to  the  correct 
use  of  water  for  influencing  both  the  lymph  vessels  and  the  general 
circulation.  For  instance,  a  warm  bath  or  compress  will  enhance  the 
absorption  of  lymph  ;  if  followed  by  a  cold  procedure  (bath,  douche), 
would  empty  the  vessels  and  send  their  contents  iuto  the  general  cir- 
culation. It  is  evident  that  we  have  here  an  effective  hydrothera- 
peutic  measure  based  upon  strict  physiologic  facts. 

*Wratsch,  No.  9,  1893. 
t  Wratsch,  No.  39,  1893. 
|  Blatter  f.  klin.  Hydrotherapie,  January  and  February,  1901. 


RATIONALE  OF  THE  ACTION  OF  WATER  IN  HEALTH.        71 

CONCLUSIONS. 

From  all  these  experiments  and  observations  upon  the  influence  of 
hydriatic  procedures  in  health,  made  under  fairly  reliable  conditions 
and  precautions,  by  different  investigators,  it  may  be  gathered,  despite 
some  difference  of  opinion  and  deductions,  that  the  changes  produced 
by  the  thermic  and  mechanical  stimulation  arising  from  hydriatric  pro- 
cedures are  very  intense  and  far-reaching .  The  inference  is  as  clear  as 
day  that  an  enormous  influence  must  be  exercised  by  procedures  which 
impress  such  changes  upon  the  calibre  of  the  vessels,  the  action  of  the 
heart,  and  the  composition  of  the  blood  in  health  ;  and  that  its  effect  in 
disease  must  be  equally  pronounced. 

To  guide  and  direct  this  effect  into  the  proper  channel  and  evoke 
such  changes  in  the  circulation  as  would  remove  stasis,  fill  certain 
vascular  areas,  and  deplete  others — are  the  aims  of  judicious  hydro- 
therapy. 

The  enormous  power  for  good  or  evil  with  which  the  physician  is 
thus  armed  has,  we  trust,  been  made  evident  by  the  experiments  de- 
tailed above. 

INFLUENCE   OF   HYDRIATIC  APPLICATIONS   UPON   THE  RESPIRATION. 

It  has  been  clearly  shown  that  all  water  applications  considerably 
below  or  above  the  skin  temperature  act  as  thermic  irritants.  Physi- 
ologists agree  that  the  respiratory  centre  is  most  easily  affected  by 
nervous  impulses  conveyed  to  it  from  various  parts  of  the  living  organ- 
ism. Impulses  from  almost  every  sentient  surface  or  passing  along 
almost  every  sensory  nerve  may  modify  respiration.  Experiments  on 
animals  show  clearly  that  stimulation  of  sensory  nerves  deepens  in- 
spiration. The  influence  of  stimuli  applied  to  the  skin  is  peculiarly 
intense,  as  is  evidenced  by  the  universal  use  of  cold  and  heat  applied 
to  the  skin  for  purposes  of  resuscitation  of  the  newly  born. 

There  are  probably  two  sensory  tracts  of  nerve  fibres  passing  from 
the  cutaneous  surface  to  the  respiratory  centre ;  viz. ,  fibres  for  inhibi- 
tion and  for  excitation. 

When  a  very  cold  or  a  very  hot  bath  is  entered,  a  deep  inspiration  is 
initiated,  which  is  interrupted  by  spasmodic  efforts.  If  the  bath  is  con- 
tinued, the  respiratory  movements  become  regular  because  the  tempera- 
ture contrast  which  is  essential  to  all  excitations  has  ceased,  and  the  cir- 
culation adapts  itself  to  the  changed  condition  in  the  blood  distribution. 

The  greatest  irritation  of  the  respiratory  centre  is  produced  by  cold 
applications,  especially  upon  the  chest  and  abdomen.  The  phrenic 
nerve  probably  is  irritated  in  these  cases,  giving  rise  to  spasmodic  action 
of  the  diaphragm,  which  seems  to  threaten  cessation  of  breathing. 
The  respiration  remains  deeper  for  a  considerable  time.  As  a  result, 


72          THE   PRINCIPLES   AND    PRACTICE   OF   HYDROTHERAPY. 

Winternitz  and  Pospischl  have  shown  an  unmistakable  increase  of 
C03  elimination.* 

Exposure  of  the  naked  body  to  cold  produces,  according  to  Fried- 
rich,  f  a  decided  increase  of  oxygen  consumption,  in  proportion  to  the 
intensity  of  the  cold.  The  projection  of  cold  water  upon  the  body  also 
produces  an  increase  of  oxygen  consumption  and  C03  excretion  in  warm- 
blooded animals. 

According  to  Wick,J  who  experimented  upon  himself,  the  hot 
bath  influences  the  respiration  peculiarly.  Even  at  102°  F.  the  fre- 
quency of  respiration  was  diminished;  it  became  deeper  and  re- 
mained partially  so  in  the  subsequent  packs.  In  baths  of  107.5°  F.  to 
111°  F.  a  sense  of  constriction  occurred,  connected  with  a  feeling  of 
tightening  of  the  larynx,  which  ceased  at  once  when  the  neck  was 
raised  out  of  the  water. 

Hot  baths  regularly  produced  a  marked  retraction  of  the  abdomen, 
which  increased  with  the  heat.  This  seemed  to  be  a  reflex  manifesta- 
tion, like  the  slowing  of  the  respiration.  The  latter  may  be  due  to 
the  influence  of  changed  blood  upon  the  respiratory  centre.  But  the 
reflex  theory  is  more  probable,  as  the  retraction  is  brought  about  by 
the  action  of  hot  water  on  the  peripheral  cutaneous  nerves.  The  phe- 
nomenon is  remarkable,  because,  under  the  influence  of  heated  blood 
upon  the  respiratory  centres,  there  is  usually  rapid  and  shallow  breath- 
ing. Probably  both  causes  are  at  work,  for  prolonged  response  to  the 
hot  batli  may  weaken  the  reflex  and  allow  the  heat  alone  to  operate. 
Topp  found  the  respiration  decidedly  quickened  and  staccato  fashion 
in  a  bath  of  113°  F.  to  115°  F. 

Baelz,  who  has  written  fully  upon  the  Japanese  hot  baths,  says 
that  the  respiration  is  at  first  little  affected,  but  becomes  more  fre- 
quent and  shallow,  an  experience  which  I  have  frequently  verified. 
The  dyspnoea  produced  by  heat  has  been  shown  by  Claude  Bernard  to 
be  due  to  reflex  action  exerted  by  the  heated  blood  upon  the  respira- 
tory centre.  Frick  and  Goldstein  produced  dyspnoea  by  allowing 
water  at  158°  F.  to  circulate  around  the  carotid  arteries  of  animals. 

Prolonged  hot  baths,  which  tend  to  raise  the  body  temperature, 
accelerate  the  respiration  and  pulse.  The  latter  becomes  more  com- 
pressible, though  full  and  bounding;  the  former  is  deepened. 

H.  Winternitz  (Halle)  §  concludes  from  some  apparently  trust- 
worthy experiments  on  a  medical  student  that  hot  baths  produce  an 

*  "  Neue  Untersuchungen  tiber  den  respiratorischen  Gaswechsel  unter  ther- 
mischen  und  mechanischen  Einfliissen,"  1893. 

f  Hayem  :  "Lemons  de  Therapeutique, "  vol.  i.,  1894. 

\ "  Ueber  die  physiologische  Wirkung  verschiedener  warmer  Bader,  " 
Wien  :  Wilhelm  Braumuller,  1894,  p.  150. 

§  "  Einfluss  heisser  Baeder  auf  den  respiratorischen  Stoffwechsel  des  Men- 
schen."  Abdruck  aus  dem  klinischen  Jahrbuch,  siebenter  Band,  Jena,  G. 
Fischer,  1899,  p.  19. 


RATIONALE   OF   THE   ACTION   OF   WATER   IN   HEALTH.  73 

increase  in  the  chemical  activity  of  the  respiratory  function,  and  that 
in  consequence  there  ensues  an  enormous  increase  of  oxygen  consump- 
tion and  C02  excretion,  which  exceed  even  those  observed  in  fevers  (20 
per  cent).  Even  when  the  body  temperature  was  not  materially  ele- 
vated by  the  warm  bath,  and  the  respiratory  mechanism  remained 
unchanged,  the  change  obtained  in  seven  examinations  made  on 
different  days  during  hot  baths  of  30  minutes'  duration  was  an 
average  increase  of  oxygen  consumption  of  78  per  cent  and  an  average 
increase  of  C0a  excretion  of  91  per  cent.  That  this  enhancement  of  re- 
spiratory activity  continued  for  some  time  was  demonstrated  by  seven 
observations,  made  on  an  average  of  53  minutes  after  the  removal  of 
the  individuals  from  the  bath,  when  an  increase  in  oxygen  consump- 
tion of  22  per  cent  and  an  increase  in  CO2  excretion  of  16  per  cent 
were  still  observed.  These  changes  are  not  attributed  by  H.  Winter- 
nitz  altogether  to  an  enhancement  of  cardiac  and  pulmonary  labor,  be- 
cause after  deducting  the  effects  of  the  latter  and  including  the  in- 
creased perspiration,  all  of  which  were  in  proportion  to  the  temperature 
and  duration  of  the  baths,  there  remained  still  30  per  cent  of  the  in- 
crease unaccounted  for. 

The  observations  of  Rubner  also  show  a  decided  increase  of  respir- 
atory function  after  hot  baths.  The  latter  being  of  short  duration, 
however,  the  increase  was  much  smaller. 

Numerous  experiments  made  in  the  Hydriatric  Institute  upon  the 
healthy  male  attendants,  and  upon  patients  under  treatment  for  vari- 
ous diseases  which  did  not  preclude  their  following  their  vocations, 
showed  the  author  that  the  impingement  of  water  at  ten  or  more 
degrees  below  the  normal  body  temperature  produces  sudden  spas- 
modic inspiratory  efforts,  which  seem  to  be  checked  immediately 
after  being  initiated  and  often  alarm  the  person  exposed  to  it. 
Very  soon,  however,  if  mental  agitation  subsides  and  equilibrium  is 
established,  the  inspirations  become  deeper  and  the  expiration  propor- 
tionately more  active.  The  respirations  are  increased  in  number  dur- 
ing the  bath  if  it  be  very  cold,  unless  shivering  is  induced,  which  pro- 
duces staccato  breathing.  After  the  cold  bath  or  douche  respiration  is 
affected  by  the  extent  to  which  reaction  ensues.  If  the  latter  be  good 
the  respirations  become  much  deeper,  the  patient  feels  that  more  air 
enters  the  lungs.  For  this  reason  all  cold  hych  iatric  applications  should 
be  followed  by  moderate  exercise  in  fresh  pure  air. 

If  the  mechanical  influences  of  certain  hydriatic  procedures  are 
added  to  the  thermic,  as  in  douches,  for  instance,  the  effect  upon  the 
respiratory  centre  becomes  enhanced.  The  same  influences  are  exerted 
by  thermic  and  mechanical  irritants  upon  the  respiration,  which  have 
been  more  fully  referred  to  in  connection  with  the  circulation;  the 
chief  difference  to  be  observed  lies  in  the  greater  sensitiveness  of 


74 


THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 


the  respiratory  centre,  and  its  more  ready  response  to  excitation  from 
the  periphery.  The  latter  offers  a  fertile  field  for  further  experimen- 
tation for  the  purpose  of  ascertaining  the  precise  influence  of  moder- 
ate and  gradually  increased  hydriati-ic  applications  to  the  periphery, 
upon  the  respiration  and  its  functional  dependencies.  In  disease, 
the  results  of  such  experimentation  would  be  extremely  useful.  We 
have  a  crude  exemplification  <of  these  virtues  in  the  application  of 
hot  or  cold  plunges  and  in  affusion  in  the  broncho-pneumonia  of  chil- 
dren, in  which,  perhaps,  the  chief  effect  arises  from  the  stimulus  con- 
veyed through  the  sensory  filaments  from,  the  skin  to  the  respiratory 
centre,  which,  being  overwhelmed  by  the  disease,  fails  to  respond  to 
the  increasing  demands  made  by  accumulation  of  C02  in  the  blood. 
Deepened  inspiration  and  forcible  expiration  further  expulsion  of 
retained  secretions. 

The  more  precise  adaptation  of  definite  temperature  to  prevailing 
conditions  may  be  learned  from  extended  experimentation  on  the  in- 
fluence of  thermic  and  mechanical  irritants  upon  the  respiration. 

Trustworthy  observations  in  the  laboratory  are  of  great  interest  in 
this  connection — Rubner  *  investigated  with  the  Zunz  apparatus  the 
effect  of  short  baths  and  douches,  as  they  are  applied  in  practice,  upon 
the  respiratory  function.  That  the  latter  is  greatly  enhanced  is  evi- 
denced by  the  following  increased  average  percentages  after  short 
baths : 


Bath 

Vol.  of  Air 

COj 

o 

Resp.  Quotient 

16°  (  61°  F.) 
30°  (  86°  F.) 
33°  (  91°  F.) 
40°(104°F.) 

44°  (111°  F.) 

i 

+22.9 
+  7.3 

+  1.8 
4-16.1 
+18.8 

+64.8 
+31.0 
-  1.8 
-  3.9 

+32.1 

-(-46.8 
+16.2 
+  6.2 
+  3.2 
+17.3 

0.86:  1.00 
0.95:  0.93 
0.87:  0.90 
0.86:  0.90 
0.86:  1.00 

This  summary  shows  clearly  that  baths  of  61°  F.  produced  a  de- 
cided increase  of  the  respiratory  function,  that  baths  of  91°  F.  produce 
little  effect,  and  that  a  rising  bath  temperature  again  increases  its  effect. 

An  interesting  finding  was  that  the  effect  of  the  douche  at  the 
same  temperature  was  double  that  of  a  short  bath.  A  douche  of  61° 
F.  increased  the 

Volume  of  air 54.5  per  cent. ;   a  bath,  22.9  per  cent 

CO,  exhalation 149.4    "       "        "     "      64.8    " 

Oxygen  consumption..  110.1    "       "        "     "      46.8    "       " 

Rubner  also  investigated  the  after-effects  of  hydriatric  procedures  and 
*  Archiv  f.  Hy.gienei  1903,  46. 


RATIONALE   OF   THE   ACTION   OF   WATER    IN    HEALTH.  75 

found  that  practically  they  disappear  in  an  hour.  This  is  probably 
due  to  the  fact  that  the  individuals  were  not  permitted  to  exercise 
after  the  treatment,  a  condition  which  does  not  exist  in  practice.  Ex- 
ercise, he  admits,  would  increase  the  effect  of  these  lung  gymnastic 
exercises  under  low-  and  high-temperature  baths. 

INFLUENCE  OF    HYDRIATIC    PROCEDURES    UPON  THE  MUSCULAR 

SYSTEM. 

This  interesting  subject  has  until  recently  received  insufficient  at- 
tention. It  has  been  well  worked  out  by  two  Italian  physicians,  Vinaj 
and  Maggiori.*  These  experiments  are  regarded  by  all  who  have  felt 
interested  in  the  scientific  development  of  hydrotherapy  so  valuable 
a  contribution  that  a  detailed  account  of  them  must  add  to  the  ex- 
planation of  the  rationale  of  various  hydriatric  procedures.  They  are 
cited  in  extenso,  at  this  point,  because  they  lend  greater  force  to  the 
true  explanation  of  the  action  of  the  douche.  The  authors  gave  an 
account  of  the  experiments  in  an  open  letter  to  Professor  Mosso,  the 
well-known  Italian  physiologist.  They  undertook  a  series  of  investi- 
gations with  the  ergograph,  invented  by  Mosso,  in  order  positively  to 
establish  the  effect  of  the  most  important  hydro-therapeutic  procedures 
upon  the  resistance  of  the  muscles  to  fatigue.  At  the  present  time  exact 
investigations  upon  this  subject,  which  is  important  from  a  hygienic 
as  well  as  from  a  therapeutic  standpoint,  are  wanting.  The  stimulat- 
ing or  depressing  effect  on  the  muscular  system  produced  by  many  of 
the  most  commonly  used  hydriatic  applications  has  not  entirely  escaped 
the  great  masters  of  medicine,  but  the  little  which  is  known  up  to  the 
present  time  is  the  result  of  the  simple  subjective  and  direct  ob- 
servation of  the  manifestations  without  any  experimental  proof  to 
demonstrate  the  correctness  of  this  subjective  observation.  Experi- 
ments made  with  the  dynamometer  cannot  be  regarded  as  scientifically 
exact,  because  of  the  numerous  sources  of  error  connected  with  this 
instrument.  The  following  diagrams  represent  graphically  the  results 
of  these  experiments  with  Mosso' s  ergograph.  The  normal  "fatigue 
curve"  was  ascertained  by  several  applications  of  the  ergograph  upon 
the  flexor  muscles  of  the  middle  fingers  of  both  hands,  the  instrument 
carrying  a  weight  of  three  kilograms,  and  registering  the  contractions 
every  two  seconds.  The  same  conditions  were  observed  in  all  subse- 
quent observations.  Two  and  a  half  hours  after  this  "  fatigue  curve" 
had  been  registered,  the  individual  was  placed  in  a  tub  containing 
water  of  50°  F.  (10°  C.)  for  fifteen  seconds.  He  was  now  dried, 

*  Blatter  fur  klinische  Hydrotherapie,  1892,  vol.  ii.,  No.  15,  and  vol.  iii., 

No.  7. 


76          THE   PRINCIPLES   AND   PRACTICE   OF    HYDROTHEEAPY. 

"wrapped  in  a  woollen  cloth,  and  the  "  fatigue  curve  "  of  the  right  and  left 
middle  finger  taken.  This  experiment  was  repeated  three  times  dur- 
ing the  day;  out  of  eight  "fatigue  curves"  thus  obtained  the  follow- 
ing are  selected  (Figs.  10  and  11).  These  curves  indicate  (the  figures 


FIG.  10.— Normal  Fatigue  Curve, 
Left  Hand. 


FIG.  11.— Normal  Fatigue  Curve, 
Right  Hand. 


given  are  here  omitted)  the  extent  of  the  work  furnished  by  these 
muscles.  The  middle  finger  of  the  right  hand,  contracting  with  the 
greatest  exertion  until  completely  fatigued  in  order  to  raise  a  weight 
of  three  kilograms  every  two  seconds,  was  capable  under  normal  con- 
ditions of  completing  fifty  contractions,  corresponding  to  mechanical 
work  of  5,139  kgm. ;  while  after  the  cold  bath  the  same  muscle  could 
complete  seventy-four  contractions  before  it  was  fatigued,  which  cor- 
responds to  a  mechanical 
work  of  9,126  kgm.  This 
simple  and  exact  experi- 
ment demonstrates  that  the 
cold  bath  produces  a  con- 
siderable increase  of  the 
working  capacity  of  the 
muscles. 

The  diagram  indicates 
that  in  the  normal  fatigue 
curve  (Fig.  12)  there  is  a 
gradual  lowering  of  the  lines, 
each  line  showing  the  extent 
of  the  contraction.  A  grad- 
ual weakening  of  the  muscles 


FIG.  12.— Fatigue  Curve,  Right  Hand,  after  bath,  50°, 
for  15  seconds.  . 


RATIONALE   OF   THE   ACTIOX   OF   WATER   IX   HEALTH. 


77 


is  evident,  at  first  followed  by  a  rapid  diminution  of  strength.  It 
will  be  seen  that  the  "fatigue  curve"  after  the  cold  bath  differs 
decidedly  from  this  normal  curve,  as  it  shows  the  continuation  of  mus- 


FIGS.  13  and  14.— Fatigue  Curves  after  Gradually  Cooled  Bath. 

cular  power  for  nearly  one-half  of  the  period,  and  its  very  gradual 
diminution  to  the  end. 

The  gradually  cooled  bath  furnished  an  interesting  "fatigue  curve." 
The  water  had  a  tem- 
perature of  96.5°  F. 
when  the  individual, 
a  student  of  medi- 
cine, twenty  -  seven 
years  of  age,  entered 
it  after  his  "  fatigue 
curve"  had  been 
noted.  Five  minutes 
elapsed,  when  the 
outflow  was  opened 
and  cold  water  was 
admitted,  until  the 
temperature  of  the 
water  was  68°  F.,  and  FIG.  is.  FIG  ie.  FMJ.  17. 

the     man    felt    Slight     FIGS.  15,  1G,  and  I'.— Effect  of  Gradually  Cooled  Bath  upon  the 
i  -it-  TT     '  Fatigue  Curve.    Fig    15,  normal  curve;  Fig.  16,  after  active 

chilliness.         Upon      work i  Fjg  ir  aftw  active  work  and  bath 
emerging    from     the 

bath  the  fatigue  curve  was  again  taken.      The  above  diagrams  rep- 
resent the  effect  of  this  bath  (Figs.  13  and  14). 

The  average  result  of  several  trials  shows  that  the  flexor  of  the  left 
middle  finger,  which  before  the  bath  was  capable  of  making  thirty -nine 


78          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

contractions,  corresponding  to  3,603  kgm.  of  work,  yielded  under  the 
same  conditions  after  the  gradually  cooled  bath  (96°  to  68°)  eighty-seven 
contractions,  equal  to  9,349  kgni.  of  work.  This  plain  enhancement  of 
working  capacity  is  showed  clearly  also  by  the  change  in  the  form  of 
the  "  fatigue  curve."  Before  the  bath  the  curve  8  shows  high  contrac- 
tion, which  fell  regularly  and  slowly  toward  the  middle;  slight  fluc- 
tuations in  the  rising  capacity  then  ensues,  indicating  change  in  the 
contracting  capacity ;  then  the  latter  sinks  regularly  but  much  more 
slowly.  After  the  bath  the  lines  show  a  nearly  even  height  for  a 
long  period;  then  a  slow  lowering  ensues,  gradually  ceasing.  The 
studies  of  Vinaj  upon  the  cooled  bath  have  shown  that  it  increases  the 
tone  of  the  vessels.  The  present  experiment  demonstrates  how 
powerfully  the  resistance  to  fatigue  is  enhanced  in  the  muscles,  and 
that  this  effect  depends  xipon  the  thermic  as  well  as  upon  the  mechani- 
cal action  of  the  procedure.  So  far  as  the  former  is  concerned,  cold 
increases  the  muscular  working  capacity,  while  warmth,  when  not 
combined  with  a  mechanical  effect,  diminishes  muscular  power,  as  is 


Flo.  18.— Normal  Fatigue     FIG.  19.— After  FIG.  20.— After  Wet 

Curve.  Labor.  Sheet. 

well  known.  When,  however,  warm  procedures  are  combined  with 
mechanical  effects,  as  in  ablution,  douches,  and  rubbings,  there  en- 
sues a  distinct  elevation  of  the  muscular  capacity,  which  is  always 
less  than  that  observed  after  cool  and  still  less  than  that  observed 
after  cold  or  alternating  procedures.  These  effects  will  be  more 
clearly  delineated  by  diagrams  when  the  rationale  of  douches  is 
reached. 

A  complete  separation  of    the   purely   thermic   action   from   the 
mechanical  is  not  reached  by  these  experiments;  it  appears,  however, 


RATIONALE   OF   THE  ACTION   OF   WATER   IN   HEALTH.  70 

that  the  maximum  effect  may  be  reached  by  cold  applications.  Not 
alone  do  certain  hydriatic  procedures  increase  the  working  capacity  of 
the  muscles;  they  also  restore  the  latter  when  it  has  been  used  up  by 
exercise  or  labor. 

The  effect  of  hydriatic  procedures  upon  muscles  ivhlck  have  been 
fatigued  is  well  brought  out  by  later  experiments  of  Vinaj  and  Mag- 
giora.  *  Their  diagram  shows  the  effect  of  a  general  cold  bath  upon  the 
flexor  muscles  of  the  right  middle  finger  with  a  weight  of  four  kilo- 
grams and  a  rhythm  of  two  seconds  similar  to  Figs.  15,  16,  17,  and 
demonstrates  that  the  effect  of  fatigue  is  entirely  removed  by  the 
cold  bath. 

The  effect  of  rubbing  with  a  cold  sheet,  upon  the  capacity  of  work 
of  a  muscle  which  has  been  fatigued,  is  graphically  shown  in  the  sub- 
joined diagram  by  Vinaj  and  Maggiora  (Figs.  18,  19,  20). 

This  diagram  shows  not  only  a  removal  of  the  fatigue  but  the 
establishment  of  a  muscular  capacity  superior  to  that  shown  by  the 
diagram  representing  the  normal  "  fatigue  curve. "  These  observations 
have  been  fully  confirmed  by  Kellogg,  f 

INFLUENCE  OF  HYDRIATIC  PROCEDURES  UPON  TISSUE  CHANGE. 

The  influence  of  hydriatic  procedures  upon  the  circulation,  respira- 
tion, and  muscular  action  has  been  fully  detailed.  It  has  been  shown 
that  the  effect  of  these  procedures  is  f  ar- reaching  in  health ;  that  not  only 
the  quantity  of  blood  but  its  composition  also  in  various  organs  and  parts 
of  the  body  are  controlled,  that  oxygen  intake  and  CO:  outgo  are  enor- 
mously increased,  that  heat  production  and  elimination  are  decidedly 
influenced  (see  page  73),  and  that  muscular  activity  is  enhanced. 
Since  functional  activity  is  the  chief  agency  in  producing  tissue  change, 
and  this  functional  activity  depends  upon  the  blood  supply  in  the  organs, 
we  may  by  influencing  the  latter  readily  exercise  a  powerful  effect  upon 
the  former. 

That  thermic  and  mechanical  irritation  applied  by  means  of  water 
upon  the  cutaneous  surface  does  arouse  cell  activity  and  does  affect 
tissue  change  has  been  very  generally  accepted.  Proof  is  not  wanting 
that  this  well-recognized  fact  is  based  upon  substantial  experimental 
data.  Many  laboratory  experiments  have  been  made  with  a  view  of 
furnishing  actual  demonstrations  of  the  influence  of  hydriatic  proced- 
ures upon  tissue  change.  Among  these  may  be  mentioned  the  classi- 
cal experiments  of  Liebermeister  and  Goldscheider,  showing  a  constant 
increase  of  C03  production  after  the  application  of  cold.  These  deduc- 
tions have  been  confirmed  by  Roehrig  and  Zuntz,$  by  their  careful 

*  Blatter  f  iir  klinische  Hydrotherapie,  July,  1893. 
\  "Rational  Hydrotherapy, "  p.  1122,  1901. 
1  Pfliiger's  Archiv,  1871. 


80          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

experiments  in  the  Bonn  Laboratory.  Not  only  was  Lieberiueister's 
idea  found  correct,  but  it  was  clearly  shown  that  the  consumption  of 
oxygen  was  subject  to  changes  depending  upon  the  temperature  of  the 
surrounding  medium.  Roehrig  and  Zuntz  found  that  changes  in  the 
intensity  of  tissue  metamorphosis  appeared  to  be  traceable  to  certain 
cutaneous  nerve  fibrils,  which  were  excited  by  cold.  These  nerve 
fibrils  could  also  be  aroused  by  other  stimuli,  such  as  strong  salt  baths, 
with  the  same  effect  of  increasing  tissue  change.  An  interesting  point 
in  connection  with  these  experiments  was  that  these  increased  oxida- 
tion processes  seemed  to  be  located  in  the  muscles,  through  their  nerve 
supply,  and  that  the  muscles  need  not,  for  this  purpose,  be  aroused 
sufficiently  to  produce  visible  contractions.  This  was  made  evident 
by  experiments  made  upon  animals  in  which  the  innervation  of  the 
muscles  was  placed  in  abeyance  by  arrow  poison.  In  such  animals 
tissue  change  was  not  only  not  increased  by  cold  but  was  even  reduced 
one-half. 

Roehrig  and  Zuntz  concluded  that  the  source  of  tissue  changes  in 
the  animal  economy  when  affected  by  cold  lies  in  the  innervation  of 
the  muscles,  and  this  is  confirmed  by  the  trite  physiological  fact  that 
the  larger  part  of  all  combustion  processes  occurring  in  the  animal  body 
may  be  traced  to  the  muscles. 

A  conscientious  and  painstaking  contribution  to  this  subject  is  fur- 
nished by  the  excellent  monograph  on  the  behavior  of  tissue  changes  in 
hydriatic  therapeutics  by  Dr.  Alois  Strasser,  the  intelligent  and  learned 
assistant  of  Professor  Winternitz  in  the  Allgemeine  Poliklinik  of 
Vienna,  whose  views  I  propose  to  reproduce  as  fully  as  space  will 
permit. 

Strasser  refers  to  the  fact  which  I  have  elsewhere  insisted  upon, 
that  the  action  of  all  thermic  irritants  is  reflex.  The  contraction  of  the 
peripheral  vessels  followed  by  the  elevation  of  the  tone  of  the  vessels 
in  the  muscular  tissues;  the  increase  of  cardiac  activity  by  the  reflex 
invigoration  of  the  heart  muscle  through  the  increase  of  resistance  in 
the  circulation;  the  deepening  and  increased  frequency  of  the  respira- 
tion— all  these  are,  as  he  correctly  states,  reflex  processes,  by  reason  of 
which  a  powerful  change  is  produced  in  the  biochemical  functions  of 
the  organism. 

"  The  entire  exchange  of  products  in  the  organism  produced  by  the 
building  up  and  destruction  of  its  component  elements  is  the  effect  of 
the  vital  activity  of  the  cell,  whose  function  we  may  trace  in  its 
various  changes  and  gradations  by  means  of  more  or  less  complicated 
methods,  chiefly  by  investigating  the  end  products  arising  from  the 
destruction  of  tissues.  These  methods  were  also  necessary  in  order  to 
determine  the  changes  produced  by  thermic  irritants  throughout  the 
entire  course  pursued  by  the  processes  involved  in  tissue  change. 


RATIONALE   OF   THE   ACTION   OP    WATER   IN   HEALTH.  81 

Winternitz  and  Pospischl  have  shown  the  influence  of  thermic  irri- 
tants upon  the  respiratory  exchange  of  gases;  they  found  in  the  very 
decided  increase  of  oxygen  consumption  and  C02  elimination  evidence 
that  the  oxidation  processes  in  the  body  were  powerfully  enhanced  by 
these  influences. 

"  Bartels  was  the  first  to  ascertain  the  behavior  of  urea  under  the 
influence  of  vapor  baths.  He  increased  the  temperature  of  a  man  by 
exposing  him  from  twenty  minutes  to  an  hour  and  a  half  to  a  hot  vapor 
bath,  to  a  point  beyond  40°  C.  During  the  first  days  of  this  artificial 
heat  retention  there  was  a  pronounced  diminution  of  urine  down  to 
600  c.c. ;  the  excretion  of  urea  appeared  to  be  increased;  but  on  the 
fourth  day,  when  the  urine  had  gone  down  to  400  c.c.,  the  first  dimi- 
nution was  noticed  in  the  urea  excretion ;  on  the  fifth  day,  however, 
after  the  bath  had  been  discontinued,  the  urine  again  increased  up  to 
1,900  c.c.,  which  was  accompanied  by  an  increased  excretion  of  urea. 
Every  rise  of  body  temperature  must  be  accompanied  by  an  increased 
destruction  of  the  elements  of  the  organism,  oxidation  processes  hav- 
ing, according  to  Naunyn,  great  similarity  to  fermentation  processes, 
whose  activity  is  in  accordance  with  the  height  of  the  temperature. 
The  result  of  Bartels'  experiments  confirmed  this,  inasmuch  as  the 
urea  fluctuated  between  21.9  and  24.9  gm.  between  the  beginning  and 
the  termination  of  the  bath  period,  while  the  largest  amount  of  urea 
during  the  bath  days  was  34.6  gm.  Naunyn  confirmed  Bartels'  find- 
ings by  a  demonstration  of  the  effect  of  simple  heat  retention  in  a 
poodle  weighing  17.8  kgm.,  which  produced  a  decided  increase  of  urea 
(about  fifty  per  cent).  The  same  results  were  obtained  by  Schleich, 
who  experimented  on  himself  and  two  other  individuals  with  warm 
baths  of  39°  to  42°  C. ;  he  discovered  an  increase  of  the  entire  nitro- 
gen and  urea  excretions,  which  was  followed  after  a  time  by  diminu- 
tion of  nitrogen  excretion  in  the  effort  to  restore  the  disturbed  nitrogen 
equilibrium.  Kosturin,  Godlewsky,  and  Richter  confirmed  these 
results.  Senator  and  Makowiecky  reached  opposite  results. 

"  Formanek  made  some  positive  experiments  to  settle  this  question. 
He  increased  the  temperature  of  the  body  by  a  hot-air  bath  of  65°  C. 
for  twenty  minutes,  followed  by  a  vapor  bath  of  41°  for  fifteen 
minutes  and  terminated  by  a  lukewarm  douche.  He  ascertained  that 
one  hot-air  bath  or  vapor  bath  scarcely  changed  the  nitrogen,  but  that 
after  two  such  baths  had  been  taken  on  successive  days  a  decided  in- 
crease of  nitrogen  elimination  was  observed  on  the  second  bath  day, 
which  continued  to  the  following  day.  Five  hot  vapor  baths,  taken 
during  three  days  had  a  similar  effect.  It  would  seem,  therefore,  that 
much  depends  on  the  duration  and  intensity  of  the  temperature  eleva- 
tion produced  by  the  bath,  which  would  explain  the  somewhat  differing 
6 


815          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

observations  previously  made  by  others.  The  urea  excretion  kept 
pace  with  the  movement  of  nitrogen ;  that  is,  when  nitrogen  was  in- 
creased the  uric  acid  was  excreted  in  greater  quantity.  The  examina- 
tion of  the  blood  showed  each  time  diminished  leucocytosis.  (This 
result  is  in  accordance  with  experiments  of  Lowey  and  Breitenstein, 
p.  57.) 

"  Experiments  with  cold  baths  upon  the  influence  of  tissue  change 
are  not  so  numerous,  but  the  results  almost  completely  agree. 

"  Dommer  found  an  increase  of  nitrogen  elimination  after  a  bath  of 
8°  to  10°  E.,  lasting  half  an  hour;  the  same  result  was  obtained  by 
Flavard  and  Lepine  in  starving  dogs,  in  which  a  very  considerable  in- 
crease of  nitrogen  elimination  was  produced  by  a  bath  of  4°  to  2.5° 
C.,  lasting  fifteen  minutes. 

"  Formanek  made  some  exact  observations  on  this  point  also  on  a 
medical  student.  The  results  of  these  examinations,  made  with  great 
care  in  order  to  eliminate  errors,  were  as  follows.  After  a  single  cold 
bath  the  excretion  of  nitrogen  was  scarcely  changed,  but  when  two  cold 
baths  daily  were  given  on  three  successive  days,  so  that  a  more  decided 
abstraction  of  heat  took  place,  the  elimination  of  nitrogen  in  the  urine 
increased  markedly  on  the  bath  days — from  13.43  to  14.51  gm.  The 
sum  of  all  the  nitrogen  excreted  by  urine  and  faeces  was  nearly  1.5 
gm.  larger  than  on  the  normal  days,  but  it  exceeded  the  quantity  of 
the  nitrogen  taken  in,  so  that  during  the  six  bath  days  an  average  of 
0.59  gm.  of  nitrogen  taken  from  the  body  albumin  was  excreted. 
The  excretion  of  uric  acid  generally  kept  pace  with  the  excretion  of 
nitrogen.  These  experiments  of  Formanek  are  the  only  ones  which 
reliably  represent  the  influence  of  heat  abstraction  upon  tissue  change." 

Strasser  correctly  insists  that  "  all  these  experiments  had  for  their 
object  only  the  heating  and  cooling  of  the  body,  and,  therefore,  can 
have  weight  only  as  purely  experimental  physiological  or  pathological 
observations.  They  represent  only  partially  those  conditions  which 
are  in  operation  when  thermic  procedures  are  used  for  therapeutic  pur- 
poses. The  differentiation  between  brief  and  longer  thermic  irrita- 
tions is  lacking  in  these  observations.  Such,  however,  is  imperatively 
necessary  in  judging  their  physiological  action.  A  short  application 
of  cold  must  certainly  act  differently  from  a  longer  one;  the  former  is 
followed  by  reaction,  contraction  of  the  cutaneous  capillaries,  and  an 
active  hyperaemia,  while  after  a  longer  application,  such  as  during  cold 
baths  of  three-quarters  of  an  hour,  a  veritable  spasm  of  the  cutaneous 
vessels  ensues  ;  after  which  the  circulation  in  the  periphery  is  restored 
much  more  slowly  and  tissue  change  is  probably  influenced  not  only 
quantitatively,  but  also  qualitatively,  in  a  quite  different  manner. 
Therefore  these  experiments  which  energetically  abstract  or  increase 


RATIONALE   OF   THE  ACTION   OF   WATER   IN   HEALTH.  83 

heat  are  not  calculated  to  explain  the  effect  of  the  usual  hydriatric1 
procedures.  Our  therapeutic  procedures  have  a  more  or  less  combined 
effect,  as  douches,  in  which  it  is  impossible  to  judge  each  of  its  com- 
ponent elements — duration,  force  of  impact,  etc.,  upon  the  tissue 
changes.  Just  as  in  the  douche  the  chief  effect  is  a  thermic  massage, 
we  have  in  other  procedures,  as  in  half -baths,  the  co-operation  of 
a  second  individual,  who,  by  a  mechanical  effect,  adapted  to  the 
case,  contributes  to  the  reaction  obtained  from  the  peripheral  irrita- 
tion." 

With  true  scientific  insight  into  all  the  elements  of  this  problem, 
Strasser  made  some  investigations  for  the  purpose  of  obtaining  a  cor- 
rect idea  of  the  total  effect  of  the  various  factors  involved  in  the  water 
treatment.  He  subjected  two  individuals  to  cool  and  cold  procedures 
such  as  are  usually  applied  in  hydrotherapeutic  institutions.  Without 
paying  regard  to  the  changes  of  temperature  produced  by  them,  he  con- 
fined himself  to  ascertaining  their  effects  upon  tissue  metamorphosis. 
He  refers  to  similar  investigations  made  by  Kussian  physicians  upon 
the  effect  of  temperate  (33°  C.),  cold  (15°  C.),  warm  (40°  C.),  and 
Scotch  douches  (45°  and  15°  C.),  of  four  minutes'  duration.  These 
showed  an  increase  of  nitrogen  change,  principally  after  the  Scotch 
douche  and  the  cold  douche.  The  N  assimilation  was  increase^ 
about  1.84  per  cent  in  four  cases  reported  by  one  of  these  observers, 
after  cold  douches  (17°  to  25°  C.). 

Strasser  subjected  two  young  men,  eighteen  and  twenty-eight  years 
old,  to  an  experiment,  measuring  the  daily  amount  of  nutriment,  the 
urine,  the  faeces,  etc.  The  principal  procedure  used  was  the  half- 
bath,  which  abstracts  most  heat  because  the  surface  of  the  body  is 
longest  in  contact  with  the  cold  water  and  the  mechanical  action  is  com- 
paratively slight  as  compared  with  douches,  etc.  As  is  usual,  the 
patient  was  dried  after  each  procedure  and  exhibited  a  good  reaction 
at  once. 

Without  entering  into  the  detailed  results  of  each  examination, 
and  omitting  the  tables  accompanying  the  report,  which  seemed  to 
have  been  compiled  with  the  greatest  care  and  skill,  we  will  relate  the 
results. 

"  The  excretion  of  nitrogen  was  decidedly  increased  during  the 
lath  period.  The  organism  did  not  respond  to  the  first  attack  of 
the  peripheral  thermic  and  mechanical  irritation  with  the  largest 
excretion  of  nitrogen;  only  on  the  second  day  did  the  greatest  re- 
action occur  and  the  irritation  reach  its  highest  point  of  effect. 
In  the  other  case  there  was  at  once  a  rapid  and  powerful  rise  of 
N  excretion.  The  .maximum  increase  amounted  on  the  first  day  to 


84          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

32.2,  the  minimum  on  the  third  day  to  11.33,  the  average  being 
16.43  per  cent. 

"  This  increased  N  excretion  must  be  ascribed  directly  to  increased 
activity  of  the  organism — a  more  active  change  of  nitrogen  in  the 
sense  of  the  better  utilization  of  the  food.  The  promptness  with 
which  this  effect  occurred  is  evidence  of  this  fact,  as  is  also  the  cir- 
cumstance that  the  faecal  nitrogen  was  diminished  at  the  same  time 
that  the  urine  nitrogen  was  increased — a  condition  which  was  uniform 
in  both  trials." 

In  a  second  series  of  observations  made  to  confirm  or  reject  the 
findings  of  the  experiments  referred  to,  Strasser*  formulates  his  re- 
sults as  follows:  "Hydriatic  procedures  constantly  increase  the  as- 
similation of  nitrogen,  the  increase  differing  in  intensity  in  different 
individuals ;  a  diminution  of  body  albumin  does  not  necessarily  occur  if 
the  nutrition  is  sufficient,  but  on  the  contrary  even  during  the  procedure 
albumin  may  be  added.  Eeaction  does  not  seem,  in  the  majority  of 
cases,  after  a  duration  of  three  days'  treatment  to  increase  the  effect  of 
this  stimulation.  Nevertheless  a  larger  number  of  clinical  observa- 
tions have  established  the  fact  indubitably  that  assimilation  is  de- 
cidedly and  enduringly  enhanced  by  water  treatment,  provided  the 
latter  is  sufficiently  prolonged." 

A  recent  contribution  by  Graeupner  $  demonstrates  that  Strasser's 
results  are  correct,  without  inpugning  results  obtained  on  healthy  in- 
dividuals by  cold  baths  not  administered  sccundem  artem,  but  by  physio- 
logical experimenters. 

Graeupner  justly  differentiates  between  the  different  stages  and 
forms  of  the  cold  procedure,  and  shows  what  every  experienced  hy- 
dro therapeutist  will  freely  grant.  During  the  first  stage  of  a  cold 
procedure  there  is  an  increase  of  muscular  action,  voluntary  and  invol- 
untary, which  increases  oxidation.  Graeupner,  who  has  a  large  expe- 
rience at  Nauheim,  declares  that  there  is  no  such  increase  of  oxygen 
intake  in  the  C03  bath,  because  the  patient  is  made  to  keep  quiet,  and 
the  •''  shock  "  is  neutralized  by  the  warming  effect  of  the  CO.,  globules. 
He  claims  that  when  reaction  takes  place,  either  no  change  or  a 
diminution  of  oxidation  ensues,  followed  by  a  restitution  of  albumi- 
nates  in  all  the  organs  of  the  body;  and  this  again  is  followed  in  from 
one  to  one  and  one-half  hours  by  a  slight  rise  of  rectal  temperature  and 
an  increase  of  all  oxidation  processes.  He  attributes  the  latter  to  the 
preceding  state  of  quiescence,  which  \Vinternitz  and  Pospischl  attrib- 

*"Fortschritte  der  Hydrotherapie.  Festschrift  zum  vierzigjahrigen  Doc- 
torjubilaum  des  Prof.  Dr.  W.  Winternitz, "  herausgegeben  von  Dr.  A.  Strasser 
und  Dr.  B.  Buxbaum.  Wien :  Urban  und  Schwarzenberg,  1897,  p.  249. 

f  Archiv  fur  Physikalisch-dietetische  Therapie,  1901,3,  pp.  7-9. 


RATIONALE   OF   THE   ACTION   OF   WATER   IN   HEALTH.  85 

uted  to  fatigue  and  exhaustion  of  the  striated  and  non-striated  muscu- 
lar structures,  following  the  powerful  excitation  of  cold,  but  which  he 
compares  quite  ingeniously  to  the  nutritive  processes  which  transpire 
during  sleep.  He  claims  quite  correctly  that  this  is  proved  by  clinical 
experience.  It  may  often  be  observed  that  the  body  fat  diminishes 
under  judicious  hydrotherapy  and  muscular  tissue  increases, 

Urea. — The  most  important  final  product  of  N  tissue  change  is 
urea,  being  the  result  of  vital  activity  of  the  cells  in  general.  As  the 
largest  ultimate  ingredient  of  the  urine,  urea  is  subjected  to  all  the 
coarse  fluctuations  of  N  excretion;  hence  the  absolute  quantity  of  urea 
in  Strasser's  cases  was  decidedly  higher  on  the  days  of  large  N  excre- 
tion. The  largest  increase  in  the  first  case  was  18  per  cent,  the  aver- 
age 10  pex  cent;  the  largest  in  the  second  case  was  25  per  cent,  the 
average  21.1  per  cent. 

The  rise  of  urea  during  the  bath  period  is  explained  by  Strasser  by 
the  increased  supply  to  the  organs  concerned  in  preparing  urea, 
brought  about  by  the  more  active  circulation  arising  from  reflex  irrita- 
tion ;  the  fact  that  the  relatively  increased  urea  production  lasts  be- 
yond the  N  increase  he  regards  as  evidence  that  the  increased  capacity 
of  the  organs  and  cells  concerned  in  preparing  urea,  which  is  aroused 
by  the  thermic  and  mechanical  irritation  of  the  skin,  continues  as  a 
kind  of  heightened  tone  even  after  the  original  irritation  has  ceased. 
These  findings  have  also  been  confirmed  by  Vinaj  and  Vietti. 

Uric  Acid. — Our  views  of  the  nature  of  uric-acid  formation  and 
excretion  have  recently  been  modified.  While  formerly  uric-acid  for- 
mation was  regarded  as  standing  in  a  causal  relation  to  the  quality  of 
the  food,  and  it  was  regarded  in  the  same  light  as  urea,  as  an  end 
product  of  albuminous  tissue  change,  the  doctrine  of  the  formation  of 
uric  acid  from  the  nuclein  bases  has  become  more  prominent  recently. 
The  absolute  quantity  of  uric  acid  was  increased,  in  the  first  case,  dur- 
ing the  bath  period  as  much  as  30.6  per  cent,  the  average  increase- 
being  20  per  cent,  and  on  the  day  after  the  bath  period  there  was  a 
further  increase  of  6.8  per  cent;  a  total,  therefore,  of  35.4  per  cent. 
In  the  second  case  we  have  a  very  considerable  absolute  increase  of 
uric-acid  excretion  without  any  changes  of  relation  to  the  total 
nitrogen. 

The  largest  absolute  increase  during  the  bath  period  was  27.5  per 
cent,  the  average  19.1  per  cent;  in  the  after-period  it  fell  11  per 
cent,  so  that  there  was  still  a  plus  of  8.2  per  cent  over  the  period 
before  the  bath.  The  relative  proportion  to  the  total  nitrogen  remains 
about  the  same  in  all  periods,  which  points  to  a  parallel  course  and 
therefore  to  a  similar  reaction  of  the  applied  irritant. 

According  to  Horbaczewski,  we  must  regard  the  formation  of  urie 


86          THE   PRINCIPLES   AND   PRACTICE   OF    HYDROTHERAPY. 

acid  as  directly  depending  upon  the  breaking  up  of  white  blood  cor- 
puscles. It  is  therefore  not  difficult  to  account  for  it  by  the  breaking 
up  of  the  leucocytes  which  follows  the  abundant  leucocytosis  produced 
by  peripheral  irritations  through  cold  (as  has  been  demonstrated  in 
hundreds  of  cases). 

Phosphoric  Acid. — This  constituent  of  the  urine  is  derived  under 
normal  conditions  chiefly  from  the  food ;  the  equilibrium  of  phosphorus 
may  be  easily  maintained  in  man  by  a  regular  supply  of  it. 

We  may  obtain  a  key  to  the  physiological  progress  of  digestion  and 
of  the  processes  of  destruction  of  certain  albuminoid  body  elements 
during  the  period  of  excretion  from  the  relative  proportion  of  P206 
to  the  total  nitrogen.  In  both  cases  the  large  absolute  and  relative  in- 
crease of  phosphoric  acid  during  the  bath  period  on  the  one  hand,  and 
the  sudden  rise  of  the  relative  P205  quantity  on  the  other  hand,  are 
striking.  In  the  first  case  the  largest  increase  occurred  on  the  first 
day,  reaching  one  gram  (about  44  per  cent),  the  average  quantity  during 
the  bath  period  being  increased  by  35.5  per  cent;  and  the  plus  in- 
crease after  the  bath  period  still  was  15.5  per  cent.  The  absolute  in- 
crease of  elimination  in  the  second  case  was  on  the  second  day,  amount- 
ing to  26.3  per  cent;  the  average  increase  during  the  bath  period  was 
23.8  per  cent;  in  the  after-period  the  quantity  excreted  was  still  14.4 
greater  than  before  the  bath  period. 

Strasser  claims  that  the  relative  increase  of  PaOs  after  hydriatic 
procedures  is  due  to  the  increased  breaking  up  of  phosphorus-contain- 
ing organisms,  and  he  regards  the  blood  cells,  which  are  rich  in  nu- 
clein  or  lecithin,  as  the  source  of  the  excessive  phosphoric  acid ;  in  other 
words,  the  breaking  up  of  blood  cells  furnishes  the  P206. 

According  to  the  investigations  of  Winternitz  and  other  observers, 
it  has  been  positively  ascertained  that  thermic  irritants,  especially 
cold,  acting  upon  the  periphery,  produce  a  very  pronounced  increase  of 
blood  cells,  whether  this  takes  place  in  the  liver  or  elsewhere,  and  thus 
the  increase  of  the  products  arising  from  the  destruction  of  the  blood 
cells  may  ensue.  Uric  acid  and  phosphoric  acid  may  originate  in  the 
nuclein  arising  from  the  nuclei  of  the  leucocytes ;  phosphoric  acid  may 
also  arise  from  the  lecithin  of  the  red  blood  cells.  Thus  may  be  ex- 
plained the  greater  increase  of  phosphoric  acid  over  that  of  uric  acid, 
inasmuch  as  the  former  can  be  produced  only  by  the  comparatively  few 
leucocytes,  while  the  latter  comes  from  both  kinds  of  cells. 

Moreover,  it  is  possible  that  red  blood  cells  may  break  up,  even  in 
the  circulatory  tract,  as  has  been  shown  by  numerous  investigations 
on  paroxysmal  hsemoglobinuria,  in  which  all  authors  agree  that  the 
blood  cells  are  directly  destroyed  under  the  influence  of  cold. 

In  the  last  experiments*  Strasser  discovered  that  only  a  small  pro- 

*  Loc.  cit. 


RATIONALE   OF   THE   ACTION    OF   WATER   IN   HEALTH.  87 

'portion  of  the  increased  phosphorus  excretion  originates  in  destruction 
of  tissues.  It  appeared  from  these  that  a  considerable  increase  of  this 
excretion  is  to  be  ascribed  to  a  greatly  enhanced  absorption  of  nutritive 
phosphorus  from  the  intestinal  canal,  and  that  only  a  small  amount 
(averaging  0.018  gin.)  is  derived  from  the  tissue  elements.  Strasser 
extended  his  observations  in  order  to  ascertain  the  character  of  phos- 
phorus increase,  and  discovered  the  peculiar  fact  that  the  entire 
increase  is  in  the  alkaline  phosphates  and  that  the  earthy  phosphates 
remain  unchanged  even  during  the  bath  period.  It  remains  therefore 
established  that  the  absorption  of  phosphoric  acid  is  intensely  en- 
hanced by  hydriatic  procedures.  That  this  increase  concerns  only 
the  alkalies  does  not  controvert  this  fact.  Indeed,  it  becomes  valuable 
in  ascertaining  the  source  of  the  small  remnant  of  phosphorus  which 
does  not  seem  to  be  covered  by  its  diminution  in  the  faeces.  As  the 
remainder  consists  only  of  alkaline  phosphates,  it  cannot  come  from 
the  bones,  but,  as  shown  by  the  first  experiments,  its  source  is  in  the 
destruction  of  blood  cells. 

Ammonia. — This  constituent  of  the  urine  is  a  product  of  general 
albumin  changes.  In  these  experiments  there  was  an  absolute  as  well 
as  a  relative  increase  of  the  excretion  of  ammonia,  but  the  relative  in- 
crease, which  has  great  significance,  was,  especially  in  the  second  case, 
much  less  than  might  be  expected  after  the  great  increase  of  the  total 
tissue  change,  and  especially  of  the  phosphoric  acid. 

Its  absolute  increase  is  indeed  very  large,  amounting  in  the  first 
case  during  the  bath  period  to  52.5  per  cent,  the  average  being  about 
42  per  cent;  in  the  second  case  the  largest  increase  was  42  per  cent, 
the  average  36  per  cent.  In  the  after-period  the  quantity  of  am- 
monia fell  so  rapidly  that  it  was  33  per  cent  less  than  before  the  bath 
period  in  the  first  case ;  and  in  the  second  case  it  remained  30  per  cent 
higher. 

Strasser  expected  a  larger  ammonia  excretion  after  thermic  pro- 
cedures, because  under  increased  decomposition  of  albumin  more 
organic  acids  are  formed  which  require  ammonia  for  their  neutraliza- 
tion. It  is  a  well-known  fact  that  only  those  acids  contribute  to 
acidification  in  the  organism  which  do  not  burn  up  into  carbonic  acid 
and  water,  and  nothing  is  more  plausible  than  that  these  organic  acids, 
being  burnt  up  by  the  powerfully  increased  oxidation  of  the  tissues 
due  to  thermic  procedure,  are  no  longer  capable  of  exerting  an  acidify- 
ing action  upon  the  organism. 

In  his  second  series  of  experiments*  Strasser  found  a  complete  con- 
firmation of  this  view.  He  says  that  there  is  no  escape  from  the  idea 
that  under  cold  hydriatric  procedures  acidifying  materials  are  removed  or 

*  Loc.  cit. 


88          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

at  least  destroyed.  Inasmuch  as  inorganic  acids  not  only  are  not  de- 
creased, but  are  even  increased,  only  such  acids  can  be  destroyed,  a 
result  which  seems  quite  plausible  under  the  powerful  excitation  of 
oxidation  induced  by  hydriatic  procedures. 

Schilling  *  has  demonstrated  positive  increase  of  ammonia  excretion, 
•which,  however,  he  attributes  to  a  formation  of  acid  products. 

Extractives. — Under  this  heading  Strasser  calculated  a  number  of 
elements  containing  nitrogen  (kreatin,  xanthin,  etc.),  which  in  the 
normal  condition  make  up  seven-eighths  of  the  entire  IT  quantity. 

The  quantity  of  these  extractives  sank  after  the  bath  period  to  1.5 
per  cent,  showing  that  the  largest  portion  of  the  nitrogen  was  used 
up  for  the  formation  of  the  normal  end  products  of  tissue  change,  thus 
leaving  but  a  small  portion  for  these  extractives. 

Strasser  concludes  his  valuable  observations  with  the  statement  that 
the  effect  of  hydrotherapy  upon  tissue  change  is  to  be  explained  by  the 
influence  of  these  procedures  upon  the  activity  of  the  living  organism. 
From  a  series  of  carefully  conducted  observations,  Vinaj  and  Yiettif 
(the  latter  being  the  subject  of  experimentation)  conclude  that  the  course 
of  ^tissue  change  was  decidedly  changed  on  the  days  on  which  hydriatic 
procedures  (morning  full  bath  35-10°  C.;  afternoon  shower  bath  of 
10°  C.  with  fan  douche)  were  taken.  These  notable  changes  were  evi- 
denced by  perceptible  increase  of  albumin  changes;  absolute  and  rela- 
tive increase  of  urea  and  total  nitrogen,  as  well  as  an  increase  of  phos- 
phates, chlorides,  and  ammoniates.  Diuresis  was  enhanced  and  there 
were  slight  fluctuations  in  the  reaction  of  the  urine. 

ZiegelholtsJ  offers  the  following  demonstrations  of  the  effect  of  cold 
hydriatic  procedures  upon  cellular  oxidation.  "If  a  tub  filled  with 
one-hundred  litres  of  water  at  18°  R.  is  placed  in  a  room  of  15°  R., 
for  ten  minutes,  the  water  loses  during  this  time  two-tenths  of  a  de- 
gree R.  If  a  normal  adult,  weighing  seventy-two  kilograms  and  hav- 
ing a  mouth  temperature  of  36.7°  C.,  be  placed  for  ten  minutes  in 
another  tub  of  water  at  18°  R.,  the  latter  temperature  will  rise  0.8° 
R. ;  i.e.,  the  hundred  litres  of  water  has  been  raised  nearly  £°  C.  by 
the  individual  who  has  lain  quietly  in  it.  In  order  to  raise  one  hun- 
dred litres  of  water  |°  C.,  125  calories  are  necessary.  Hence  the  in- 
dividual bathing  has  given  off  in  ten  minutes  125  calories  without  any 
reduction  of  his  own  temperature.  On  the  contrary,  the  thermometer 
shows  a  sudden  increase  of  0.2°  C.  at  the  moment  the  individual  is 
placed  into  the  cool  water,  and  his  temperature  remains  elevated  as 
long  as  he  lies  in  the  bath. 

*Deut.  ArchivMed.,  Ixxxiv.,  p.  311, 1905. 

fHydrotberapie  und  Stoffwechsel,"  by  Dr.  G.  T.  Vinaj  and  Dr.  S.  Vietti. 
Blatter  f.  klin.  Hydrotherapie,  1901,  5  et  seq. 
J  Deutsche  Medizinal-Zeitung,  53,  1897. 


RATIONALE   OF   THE   ACTION   OF   WATER    IN   HEALTH.  89 

The  author  has  obtained  similar  results  in  the  Vanderbilt  Clinic, 
under  observation  of  Drs.  Shrady,  Wittson,  and  Cleghorn.  Into  a  tub 
containing  273  litres  of  water  at  room  temperature  (73°  F.)  a  man 
with  normal  temperature  was  placed  for  ten  minutes,  without  moving. 
After  the  bath  his  temperature  was  0.1°  F.  higher.  The  water  tem- 
perature had  risen  2°  F.  This  proves  that  during  a  bath  of  ten 
minutes  273  litres  of  water  were  raised  1.3°  C.  and  therefore  355 
calories  were  produced  during  this  bath  of  ten  minutes. 

The  observations  of  Rubner  and  Ignatowski*  furnish  the  same 
results  on  the  human  subject.  There  is  an  increase  of  heat  production 
after  cold  as  well  as  hot  baths,  with  secondary  results  which  clearly 
indicate  cellular  activity  and  consequent  tissue  change. 

The  significance  of  the  loss  of  calories  is  enhanced  when  we  con- 
sider that  this  is  a  large  portion  of  the  entire  number  of  calories 
furnished  by  the  normal  organism  in  twenty-four  hours.  The  ex- 
periments of  Frankland  and  Rubner  have  shown  that  one  gram  of 
albumin  furnishes  about  4  calories  ;  125  calories  therefore  corre- 
spond to  30  grams  of  albumin.  That  this  is  an  enormous  en- 
hancement of  tissue  change  resulting  from  a  rather  mild  bath  is 
self-evident.  Larger  baths,  which  are  usually  resorted  to  when 
an  enhancement  of  tissue  metamorphosis  is  aimed  at  by  hydriatric 
procedures,  must  insure  such  a  result,  as  is  evident  from  the  author's 
experiment. 

Linser  and  Schmidt  f  experimented  on  patients  affected  by  ichthy- 
osis  who  perspired  very  little  or  not  at  all  and  therefore  readily  evi- 
denced an  increased  body  temperature.  They  found  that  there  is 
little  if  any  increased  breaking  up  of  albumin  under  39°  C.  (102.2° 
F.),  but  that  it  increased  regularly  at  a  body  temperature  of  40°  C. 
(104°  F.)  or  over.  They  concluded  that  in  fevers  not  reaching  104° 
F.  the  increase  of  albumin  decomposition  is  due  exclusively  to  the 
infection.  By  adding  carbohydrates  to  the  diet  in  artificial  hyper- 
thermia,  the  albumin  destruction  could  be  limited,  but  not  to  the  same 
extent  as  in  normal  temperature  conditions.  Accompanying  the  total 
increase  of  the  nitrogen  excretion  the  values  for  purin,  N,  ammonia, 
and  diacid  NO,  and  phosphoric  acid  were  raised.  Hot  baths  which 
produced  hyperthermia  in  men  always  produced  a  decided  rapidity 
of  respiration  with  deepening  of  the  inspiration.  There  is  a  decided 
increase  of  oxygen  intake,  amounting  sometimes  to  100  per  cent,  and 
C02  exhalation  may  be  increased  to  40  per  cent  when  baths  over  104° 
F.  are  taken. 

*  Archiv  f .  Hygiene,  1903-4. 

f'Ueber  den   Stoffwechsel    bei   Hyperthermie,"   Deutsch.  Archiv  f.   klin. 
Med.,  1905,  Bd.  79. 


90          THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

Thus  is  it  mathematically  demonstrated  that  the  physician  holds 
a  powerful  therapeutic  weapon  in  these  procedures,  which,  rightly 
used,  may  furnish  results  beyond  those  obtainable  from  any  other 
known  agent. 

INFLUENCE  OF  HYDRIATIC  PROCEDURES  ox  TEMPERATURE. 

Physiologists  are  in  accord  in  maintaining  that  the  temperature  of 
a  living  part  or  organ  depends  upon  the  amount  of  arterial  blood  cir- 
culating within  its  tissue.  The  fact  that  venous  blood  returning  from 
an  organ  in  a  high  state  of  functional  activity  is  warmer  than  the 
arterial  blood  passing  into  it,  is  alone  sufficient  evidence  of  the  propo- 
sition that  the  arterial  circulation  is  an  important  element  in  the 
equalization  of  the  body  temperature.  All  tissue  change,  all  organic 
action,  is  in  direct  ratio  to  the  quantity  of  arterial  blood  circulating  in 
an  organ,  and  therefore  depends  upon  vascular  activity,  by  means  of 
which  excretory  and  secretory  elements  are  carried  to  and  from  it. 
The  accumulated  heat  in  the  organs  is  equalized  by  the  streams  of 
blood  which  constantly  pass  through  them.  Hence  the  flow  of  arterial 
blood  controls  temperature  variations,  to  some  extent.  The  effects  of 
hydriatic  procedures  upon  the  circulation,  respiration,  and  tissue  change 
have  been  fully  enlarged  upon.  It  remains  now  to  demonstrate  how, 
by  utilizing  this  powerful  influence,  we  may  reduce  or  elevate  the  tem- 
perature in  the  human  economy.  That  the  application  of  baths  of 
/arious  kinds  is  potent  in  this  direction  has  been  accepted  since  the 
primitive  days  of  medical  investigation.  Indeed,  the  idea  that  reduc- 
tion of  temperature  is  the  chief  if  not  the  sole  attribute  of  the  bath  has 
so  strongly  rooted  itself  in  tlie  professional  mind  that  it  is  difficult  to 
dislodge  it  to-day,  when  we  have  come  to  realize  that  this  is  only  one 
of  its  valuable  manifestations. 

It  has  been  shown  ("The  Skin  as  a  Heat  Kegulator,"  page  27) 
that  there  is  no  evidence  to  prove  that  the  influence  exerted  by  exter- 
nal thermic  agents  is  traceable  to  the  heat-generating  centres.  There 
is  abundant  evidence,  however,  to  prove  that  this  influence  is  directly 
exerted  upon  that  most  important  heat-regulating  agency,  the  periph- 
eral cutaneous  circulation,  aided  in  cold  procedures  by  the  production 
of  heat  in  the  muscles,  which  are  more  or  less  contracted  involuntarily, 
as  is  evident  in  the  chill  produced  by  uncomfortably  low  temperatures, 
against  which  the  organism  defends  itself  in  this  manner.  The  mode 
of  action  in  this  direction  is  twofold. 

I  have  referred  to  the  well-known  fact  in  physical  science  that 
two  bodies  of  different  temperatures,  by  coming  in  contact,  will  at  once 
make  an  effort  to  equalize  their  respective  temperatures.  This  law 
applies  to  inanimate  bodies,  however,  and  is  only  applicable  to  the 


RATIONALE   OF   THE   ACTION   OF   WATER   IN    HEALTH.  9.1 

living  body  up  to  a  certain  point,  because  the  latter  is  endowed  with 
compensatory  powers  which  enable  it  to  resist  dangerous  encroach- 
ments from  external  temperature  agencies,  and  which  have  been  illus- 
trated fully  in  the  chapter  on  temperature  regulation. 

The  utilization  of  these  compensatory  powers  enables  us,  as  will 
be  shown,  to  influence  the  temperature  of  the  body  powerfully  in  dis- 
eased conditions,  in  which  the  comfort  and  safety  of  the  patient  are 
jeopardized  by  long  continuance  of  elevated  temperatures  or  to  enhance 
tissue  change  and  processes  of  elimination  by  elevating  the  body  tem- 
perature for  a  longer  or  shorter  period — an  effect  which  no  medicinal 
agent  is  capable  of  accomplishing. 

I  have  referred  to  the  important  fact  that  the  temperature  of  any 
portion  of  the  body  surface  may  be  reduced  or  elevated  by  its  contact 
with  media  of  different  temperatures,  until  the  death  of  the  part  by 
freezing  or  scalding  occurs,  and  that  the  inner  parts  are  protected 
against  further  destructive  invasion  by  the  intervention  of  the  dead 
part.  I  have  also  endeavored  to  emphasize  the  fact  that  temperatures 
whose  effects  fall  short  of  destroying  parts  are  prevented  from  pene- 
trating to  the  deeper  tissues  to  any  extent,  because  the  collateral  cir- 
culation is  enhanced  in  the  muscular  structures,  endowing  the  parts 
invaded  with  increased  vitality  and  resisting  capacity.  The  well- 
known  facts  that  the  muscular  tissues  are  bad  conductors,  and  that  the 
tonic  contractions  of  the  muscles  aroused  by  the  application  of  cold 
tend  to  create  more  heat,  have  also  been  dwelt  upon. 

Inasmuch,  therefore,  as  the  external  parts  of  the  body  are  well  de- 
fended against  the  direct  injurious  invasion  of  thermic  agencies,  our 
means  of  reducing  or  of  elevating  the  temperature  of  the  body  by 
hydriatic  procedures  are  very  meagre  in  health,  although  in  disease 
their  action  is  more  pronounced.  These  effects  upon  temperature  may 
be  obtained  for  comparatively  brief  periods  only,  demonstrating  that 
the  antithermic  uses  of  water  are  far  less  valuable  than  its  other 
qualities  in  febrile  conditions. 

The  sooner  this  important  point  is  mastered  by  the  profession  the 
better;  for,  as  just  stated,  the  fallacious  idea  that  cold  baths,  for  in- 
stance, reduce  temperature  by  the  direct  effect  of  the  cold  is  still  so 
firmly  fixed  in  the  minds  of  many  otherwise  well-informed  men  that 
it  is  regarded  as  axiomatic.  This  is  one  cause  of  the  misinterpretation 
of  the  rationale  of  the  cold  bath  in  fevers,  which  has  been  a  serious 
obstacle  to  the  popularization  of  this  life-saving  measure.  The  truth 
is  that  the  colder  the  bath  the  less  active  is  its  power  of  reducing  internal 
temperature.  The  temperatures  taken  in  the  mouth  and  axilla  are 
fallacious.  Errors  have  crept  into  the  estimation  of  the  effects  of  cold 
baths  upon  temperature  reduction,  by  reason  of  the  measurement  being 
taken  in  the  axilla,  as  still  seems  customary  in  some  parts  of  Germany, 


92          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHEKAPY. 

or  in  the  mouth,  as  is  mostly  done  for  convenience  in  this  country. 
Careful  observation  will  bring  the  conviction  that  if  a  thermometer  be 
held  long  enough  in  the  mouth,  axilla,  and  rectum  simultaneously  the 
temperature  will  register  almost  exactly  alike,  the  difference  being 
governed  by  the  excess  over  normal  temperature  present.  The  farther 
the  body  temperature  is  removed  above  the  normal,  the  more  nearly 
alike  will  the  three  records  be.  In  fevers  they  will  register  equally 
well  after  a  ten  minutes'  trial,  a  higher  temperature  requiring  a  shorter 
duration.  But  after  a  cold  bath,  when  the  skin  is  the  first  and  chief 
part  of  the  body  cooled,  the  axillary  temperature  is  absolutely  unreli- 
able, and  the  mouth  temperature  does  not  correspond  with  that  of  the 
rectum,  if  the  duration  of  the  measurement  be  the  same  (five  to  ten 
minutes)  as  before  the  bath.*  I  have  often  seen  the  mouth  tempera- 
ture after  a  fifteen-minutes'  bath  of  65°  in  typhoid  fever  reduced  to 
99°,  when  the  rectal  temperature  indicated  two  degrees  higher,  although 
both  were  carefully  taken  for  five  minutes. 

This  point  had  never  been  referred  to  before  the  appearance  of  my 
book  on  "The  Uses  of  Water  in  Medicine."  It  being  a  clinical  fact, 
however,  which  admits  of  no  doubt,  I  must  insist  upon  it  here,  as  I 
shall  do  elsewhere,  also,  in  order  that  the  unreasoning  prejudice  against 
the  cold  bath,  which  had  its  origin  in  the  idea  that  its  antithermic  effect 
is  in  proportion  to  the  low  temperature  of  the  bath,  may  be  removed, 
The  fact  is,  as  shown  by  Liebermeister,  f  that,  during  the  action  of 
extraordinary  heat  abstraction  from  the  external  surface,  if  its  inten- 
sity does  not  exceed  certain  limits,  the  inner  temperature  of  the  body 
does  not  fall,  but  even  rises  a  little.  This  observation  is  confirmed  by 
Aubert,  Corette,  and  others  quoted  by  Hayem  in  his  "  Legons  de  Ther- 
apeutique." 

Ignatowski  \  has  clearly  demonstrated,  by  an  improved  calorimeter, 

*  The  author  had  occasion  to  demonstrate  these  facts  to  the  very  able  and 
courteous  physicians  of  two  of  the  largest  hospitals  in  Germany.  A  patient 
with  typhoid  fever  who,  when  hisaxillaiy  temperature  reached  39°  C.  (102.2°  F.), 
had  received  baths  of  33°  C.  (91°  F.)  with  affusions  of  26°  C.,  three  times  daily, 
with  a  reduction  of  one  degree  Celsius,  was  measured  at  my  suggestion  before  the 
bath  in  recto,  mouth,  and  axilla,  all  of  which  registered  39°  C.,  because  the 
thermometer  was  held  ten  minutes.  After  the  bath  (33°  C.  for  six  minutes,  with- 
out friction),  the  axillary  temperature  was  38°  C.,  the  mouth  38.4°,  and  the  rec- 
tum 39°  C. ;  the  last  was  therefore  unchanged  as  had  been  predicted  of  so  short  a 
bath.  In  the  other  hospital  the  patient's  temperature  before  a  bath  of  33°  with 
three  affusions  of  25°  C.  and  some  friction,  the  axilla  registered  40.2°,  rectum 
40.4° ;  after  the  bath,  axilla  39°,  rectum  39.7°,  the  thermometer  being  held  fifteen 
minutes,  or  until  I  protested  that  in  half  an  hour  or  more  there  would  be  a  com- 
plete return  of  the  external  temperature  by  reaction.  The  loss  of  time  involved 
in  axillary  measurement  and  its  false  evidence  after  the  cool  bath  are  serious 
objections. 

fHandbuch  der  Pathologic  und  Therapie  des  Fiebers,"  p.  102. 

JArchivf.  Hyg.,  1904,  51. 


RATIONALE   OF   THE   ACTION   OF   WATER   IX   HEALTH.  93 

which  was  provided  with  an  anemometer  for  the  exact  recording  of 
radiated  heat,  and  a  hygrometer  for  determining  the  evaporated  moist- 
ure, that  even  baths  of  such  temperature  and  duration  as  are  applied 
in  practice  produce  the  same  effect. 

There  is  an  increase  of  heat  production  and  a  diminution  of  vapori- 
zation which  may  continue  for  two  hours  unless  reaction  is  established. 
When  the  latter  ensues,  as  is  usually  the  case,  there  is  always  a  slight 
rise  of  the  rectal  temperature. 

The  most  important  temperature  effect  of  thermic  agencies,  exter- 
nally applied,  lies  in  the  immense  power  the  latter  affords  over  the 
cutaneous  circulation.  The  investigations  of  several  physiologists  re- 
ferred to  show  that  when  a  portion  of  the  skin  is  moderately  heated 
the  temperature  of  neighboring  portions  is  lowered,  and  that  when 
cutaneous  surfaces  are  moderately  cooled,  the  neighboring  structures 
present  a  proportionally  higher  temperature.  This  effect  is  traceable 
to  the  collateral  anaemia  produced  by  afflux  of  blood  to  the  surface  to 
which  warmth  is  applied,  and  by  the  driving  of  blood  from  the  sur- 
face to  the  inner  structure  when  cold  is  applied. 

Fleury,  who  has  done  so  much  in  France  toward  explaining  hydri- 
atic  procedures  upon  physiological  principles,  offers  the  following 
results  deduced  from  careful  experiment:  "Dipping  the  body  into 
moderately  cool  water  (48°  to  58°  F.)  for  thirty  minutes  reduced  the 
temperature  of  the  surface,  while  the  inner  temperature  did  not  change 
at  all.  The  more  brief  the  application  the  colder  it  was  made,  and 
the  higher  the  surrounding  temperature  the  more  rapid  and  complete 
was  the  reaction.  The  reaction  entailing  the  re-establishment,  and 
even  the  increase,  of  the  previously  existing  temperature  depended 
upon  the  conduct  of  the  patient  after  the  applications,  it  being  more 
rapid  and  complete  after  active  and  passive  exercise  of  the  parts,  espe- 
cially in  a  warmer  surrounding  medium. 

These  simple  facts  have  again  and  again  been  verified  by  numerous 
reliable  authorities,  and  may  if  properly  grasped  lead  to  a  correct  un- 
derstanding of  many  seeming  paradoxes  in  hydrotherapy. 

In  health  the  effect  of  hydriatic  applications  upon  the  temperature 
of  the  body  is  almost  nil,  because  the  compensatory  agencies  referred 
to  are  constantly  on  guard  to  maintain  the  normal  equilibrium. 

While  the  circulation  and  respiration  may  be  readily  affected  in 
health  by  thermic  and  mechanical  irritation  conveyed  by  the  applica- 
tion of  water  to  the  cutaneous  surface,  the  internal  temperature  re- 
sponds to  its  influence  only  to  a  very  slight  extent. 

The  temperature  effect  of  cold  hydriatic  procedures  is  therefore  in 
health  mainly  perceptible  on  the  cutaneous  surface,  i.e.,  externally  only. 
Even  in  disease  much  depends  upon  the  individual  pathological  condi- 
tions which  give  rise  to  temperature  elevation.  It  will  be  shown,  for 


94          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

example,  that  clinical  observation  has  demonstrated  a  great  resistance 
of  the  high  temperature  in  the  early  days  of  typhoid  fever  to  hydria- 
tric  procedures.  Rarely,  if  ever,  will  any  cold  bath  reduce  the  tem- 
perature more  than  two  degrees  in  the  first  week  of  the  disease,  while 
in  croupous  pneumonia  even  a  moderately  cold  bath  (85°  to  80°  F.) 
may  reduce  the  temperature  from  two  to  four  degrees. 

It  is  well,  at  the  oiitset,  therefore,  to  realize  that  the  long-prevalent 
idea  that  in  its  capacity  of  reducing  temperature  lies  the  chief  strength 
of  cold  procedures  is  fallacious. 

The  Effect  of  Heat  applied  upon  the  cutaneous  surface  is  more  pro- 
nounced. The  investigations  of  Liebermeister,*  Baelz,f  Topp,J 
Hosier,  §  and  H.  Winternitz  ||  show  that  the  internal  temperatures  of 
the  body  are  positively  raised  by  prolonged  hot  baths,  which  limit  the 
diffusion  of  heat.  There  is  no  systemic  reaction  to  intensify  the  heat 
production.  On  the  contrary,  every  effort  is  made  by  the  organism 
to  restore  the  equilibrium,  as  during  cold  applications.  Hence  the  in- 
crease of  internal  temperature  is  almost  entirely  due  to  the  contact  of 
the  hot  medium  with  the  skin,  and  the  latter's  inability  to  radiate  and 
diffuse  heat.  During  the  hot-air  bath,  in  which  there  is  little  inter- 
ference with  heat  radiation  and  diffusion  by  perspiration,  the  internal 
temperature  rises,  as  we  have  observed  in  hundreds  of  instances,  from 
one-half  to  three  degrees  Fahrenheit. 

Ignatowski's^  experiments  have  confirmed  this  observation  and 
added  exact  data  regarding  heat  production,  gain  and  loss,  besides 
the  important  element  of  vaporization  of  moisture  after  hydriatric  pro- 
cedures. Although  the  data  are  not  always  uniform  they  are  suffi- 
ciently so  to  deserve  attention.  One  experiment  will  be  cited  to  illus- 
trate :  F.  was  placed  into  a  tub  calorimeter  having  a  water  temperature 
of  39°  C.  (102°  F.)  for  15  minutes.  The  bath  water  gave  up  to  the 
body  26.7  calories  in  15  minutes;  weight  before  the  bath  53.5;  after 
it,  53.2;  gain  in  axillary  temperature,  0.3°  C.;  the  organism  was 
heated  0.7°  C.,  i.e.,  it  received  37.32  calories.  The  same  subject 
being  placed  into  a  tub  of  water  at  42.5°  C.  (108.5°  F.)  received 
98.25  calories;  the  axillary  temperature  increased  1.11°  C.  —  61.451 
calories;  there  was  a  loss  of  100  per  cent  in  vaporized  moisture  and 
latent  vaporized  heat. 

Although  there  is  an  increase  of  heat  production  during  the  hot 
bath,  this  is  far  below  that  obtained  after  cold  procedures;  in  the 
former  it  amounts  to  about  30  per  cent,  in  the  latter  to  1,300  per  cent. 

*"Handbuch  tier  Path,  und  Therapie  des  Fiebers,"  Leipzig,  1875. 
fBaelz:  Verhandl.  des  XII.  Congress  f.  innere  Medicin,  Wiesbaden,  1893. 
JTopp-  Therap.  Monatshefte,  1894. 
§Mosler:  Virchow's  Archiv,  Bd.  14. 
|  H.  Winternitz:  Loc.  cil. 
*\Loc.  cit. 


RATIONALE  OF   THE  ACTION  OF  WATER   IN   HEALTH.  95 

It  is  evident  that  heat  dissipation  is  increased  immediately  after 
the  cessation  of  a  hot  procedure,  and  that  it  depends  upon  the  degree 
of  previous  warming.  The  escape  of  watery  vapor  is  distinctly  in- 
creased (sometimes  doubled  or  trebled  in  comparison  with  the  normal) 
and  represents  the  cause  of  the  increased  heat  dissipation,  although 
loss  by  radiation  and  conduction  remains  practically  unchanged.  The 
heightened  temperature  falls  in  the  secondary  period,  at  first  rapidly, 
later  gradually  in  the  course  of  about  two  hours ;  then  there  is  noted 
a  secondary  rise  previous  to  which  the  temperature  may  be  lower  than 
it  was  prior  to  the  bath.  The  usual  difference  between  the  axillary 
and  rectal  temperatures  (0.5°  C.)  is  increased  immediately  after  the 
hot  bath  by  reason  of  heat  absorbed  by  the  skin.  Heat  production 
sometimes  diminishes  immediately  after  the  bath,  still  it  frequently 
rises.  Moderate  warming  of  the  body  always  results  in  an  increase  of 
heat  production  which  after  the  lapse  of  one  or  two  hours  is  always 
still  above  that  existing  before  the  bath.  Thus  in  an  individual  tak- 
ing a  bath  of  35.5°  K.  (112°  F.)  of  two  minutes'  duration  there  was 
an  increase : 

Of  water  vaporization  from  g.  12.7  to  g.  22.59;  !•$•  hours  later  it  was  g.  15.67 
"   latent  heat  "  7.4     "      13.1;     "        "         "          "  9.1 

"  heat  dissipation  for  i  hour  from  18.8  to  g.  23.5;  1|  hours  later  it  wasg.  21.2 
"       "   production    "    i     "     from    7.04     "    19.06;  "       "       "       "  26.46 

From  these  observations  it  is  evident  that  while  the  application  of 
warm,  like  that  of  cold,  water  inaugurates  in  the  organism  decided 
changes  in  heat  production  and  heat  dissipation,  changes  which  will 
be  shown  in  the  clinical  part  to  be  capable  of  valuable  therapeutic 
utilization,  the  compensatory  processes  of  the  organism  restore  the 
temperature  equilibrium  in  health  so  completely  that  the  final  effect 
is  negative  so  far  as  temperature  elevation  is  concerned,  just  as  has 
been  shown  in  the  case  of  cold  procedures. 


CHAPTER    V. 

REACTION. 

THE  most  striking  results  of  hydrotherapy  are  obtained  from  cold 
water  applied  to  the  cutaneous  surface,  from  which  its  constringing 
action  drives  the  blood  into  subjacent  vessels.  This  action  of  cold 
water  (below  90°  F.)  is  followed  by  a  filling  of  the  previously  con- 
stricted vessels,  which  process,  together  with  certain  other  phenomena, 
refreshment,  bienaise,  and  heightened  function,  constitutes  reaction. 
The  author  does  not  regard  the  therapeutic  effect  of  warm  water  (above 
90°  F.)  applied  to  the  skin  as  due  to  the  reactive  process,  for  reasons 
which  appear  in  his  explanation  of  the  rationale  of  procedures  having 
a  temperature  above  that  of  the  body. 

Since  the  largest  proportion  of  the  procedures  to  be  enumerated 
and  described  depend  upon  the  reaction  they  evoke,  it  becomes  neces- 
sary to  consider  this  important  process  before  proceeding  to  their 
technique. 

Reaction  after  cold-water  applications  may  be  defined  as  the  re- 
sponse of  the  organism  to  temperature  invasions.  Greater  or  less 
activity  of  the  functions  of  the  organism  is,  as  has  been  shown  in  the 
preceding  pages,  the  result  of  this  defensive  effort  of  the  organism  to 
readjust  the  equilibrium  disturbed  by  the  intrusion  of  cold.  In  infec- 
tious (acute)  diseases  this  enhanced  activity  of  the  organic  functions 
is  utilized,  as  will  appear  in  the  clinical  part,  by  its  judicious  grada- 
tion, for  the  maintenance  of  the  patient's  resisting  capacity  and  for 
tiding  him  over  dangers  which  menace  the  life-sustaining  organs  under 
the  incubus  of  toxaemia.  In  chronic  diseases  this  enhancement  of 
vital  activity  invoked  by  reaction  after  cold-water  applications  be- 
comes of  paramount  value  in  restoring  functions  which  have  been  ren- 
dered dormant  or  abnormally  active  by  faulty  modes  of  living. 

The  study  of  reaction  derives  its  interest  from  these  clinical  facts, 
for  only  by  clearly  understanding  the  manner  of  its  production,  its 
rationale,  and  the  influences  which  increase  or  diminish  it,  may  we 
attain  to  that  "perfection  of  hydriatric  technique  which  enables  the 
physician  to  modify  and  adjust  its  varying  phases  to  the  removal  of 
pathologic  states  or  functional  abnormalities. 

Reaction  after  cold-water  applications  is  the  resultant  or  secondary 


REACTION.  97 

physiological  effect  of  the  latter  upon  the  sensory  terminals  and  ves- 
sels ramifying  through  the  skin. 

Clinical  observation  has  established  two  forms  of  reaction,  which, 
though  usually  acting  in  combination,  must  be  considered  separately. 

1.  Nerve  (Reflex)  Reaction. — At  the  risk  of  reiterating  trite  facts, 
the  action  of  thermic  irritants  upon  the  sensory  nerve  terminals  in  the 
skin  demands  consideration.  It  is  a  recognized  physiological  axiom 
that  such  irritants  cause  local  excitation,  and  that  the  latter  is  not 
confined  to  the  surface  irritated,  but  is  at  once  conveyed  upon  sensory 
tracts  to  the  central  nervous  system  and  reflected  thence  to  other 
parts.  Cold  being  a  thermic  irritant,  it  is  not  difficult  to  trace  most  of 
the  notable  effects  of  hydrotherapy  upon  the  above  simple  physiologi- 
cal law.  That  these  therapeutic  results  from  the  application  of  cold 
.water  cannot  be  rivalled  by  medicinal  agents  is  matter  of  daily  experi- 
ence. Nerve  reaction  is  manifested  when  the  central  nervous  system 
is  aroused  to  respond  to  the  demand  made  upon  the  cutaneous  seiisory 
terminals  by  cold  applications. 

The  first  palpable  evidence  of  nerve  reaction  is  the  sudden  gasp 
and  staccato  breathing — a  phenomenon  as  familiar  to  the  practitioner 
as  its  rationale  is  to  the  physiologist.  The  immediate  effects  of  cold 
sprinkling  upon  a  fainting  person  and  in  the  resuscitation  of  the  still- 
born infant  are  examples  of  pure  nerve  reaction. 

The  final  effect  of  nerve  reaction  is  evident  in  the  refreshment  of 
the  entire  organism  after  a  properly  applied  cold  procedure.  In  health 
the  man  whose  reactive  capacity  enables  him  to  indulge  in  the  morn- 
ing cold  plunge  testifies  to  this  result  by  his  ruddy  appearance  and 
sense  of  general  invigoration.  In  disease  each  bath  or  other  cold  pro- 
cedure gives  a  fillip  to  the  depreciated  nerve  centres  and  sends  new  life 
to  the  organs  depending  upon  them  for  functionating  force.  The  whole 
machinery  of  the  organism  receives  an  impetus  which  endures  a  longer 
or  shorter  period  in  proportion  to  the  temperature,  duration,  and  tech- 
nique of  the  cold  procedure.  Whoever  has  witnessed  how  the  dull 
eye  of  a  typhoid  patient  brightens,  and  how  the,  apathetic  countenance 
disappears  after  a  cold  friction  bath;  whoever  has  seen  him  lapse 
after  a  properly  administered  cold  procedure,  from  muttering  delirium 
or  coma  vigil  into  a  gentle  slumber,  must  be  convinced  that  the  rapid- 
ity of  the  salutary  effect  can  be  attained  only  through  an  influence 
over  the  central  nervous  system. 

That  the  degree  of  nerve  reaction  differs  as  the  extent  and  degree 
of  cutaneous  excitation  differ  is  a  subject  of  daily  observation  and 
a  fact  based  upon  established  physiological  law.  In  the  clinical  chap- 
ters the  application  of  the  latter  in  the  "  dosage  "  of  hydriatric  pro- 
cedures will  be  clearly  demonstrated,  and  it  will  be  shown  in  the 


98          THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHEEAPY. 

chapter  on  Hydriatric  Prescriptions  how  failure  to  obtain  the  best  re- 
sults may  be  traced  to  a  disregard  of  the  plain  physiological  laws  upon 
which  hydrotherapy  is  based. 

2.  Vascular  Reaction. — The  primary  effect  of  cold  applications 
upon  the  vessels  is  a  constriction  of  the  muscular  and  elastic  fibres 
enveloping  the  capillaries  and  arterioles  of  the  skin — this  is  action; 
the  secondary  effect,  return  of  blood  to  the  previously  emptied  vessels 
— this  is  reaction. 

The  effect  of  thermic  excitations  upon  the  arterioles  and  capillaries 
which  ramify  in  the  skin  has  been  fully  discussed.  The  following 
data  may  be  accepted  as  established : 

(a)  That  the  vessels  lying  in  contact  with  and  beneath  the  point 
of  a  cold  application  are  immediately  contracted  by  the  muscular  and 
elastic  cutaneous  fibres,  in  proportion  to  the  degree  and  extent  of  the 
procedure,  and  the  blood  is  accumulated  in  the  interior,  chiefly  in  the 
intra-abdominal  vessels. 

(J)  That  the  removal  of  the  cold  from  the  skin  is  followed  by  a  re- 
placement of  the  blood  which  had  been  driven  out  of  the  arterioles  and 
capillaries  in  proportion  to  the  degree  of  cold  and  duration  of  the 
procedure. 

(c)  That  prolonged  or  intense  application  of  cold  to  the  skin  pre- 
vents reaction  by  reason  of  narrowing  of  the  arterioles  and  thus  limit- 
ing the  supply  of  arterial  blood  needed  for  the  inauguration  of  reaction 
by  the  capillaries  of  the  skin. 

(d")  That  arterial  blood  rushes  into  the  empty  vessels  with  avidity, 
while  venous  blood  flows  back  more  sluggishly  (Bier,  Exp.  27  and  28, 
p.  291,  loc.  tit.)  after  withdrawal  of  the  cold. 

Thus  we  obtain  a  clear  conception  of  local  reaction  after  cold  pro- 
cedures. The  action  of  the  latter  upon  the  part  receiving  it  starts  a 
physiological  process  which  is  at  once  interesting  and  of  vast  import 
in  the  production  of  general  vascular  reaction,  through  whose  agency 
those  striking  influences  upon  hsematosis,  nutrition,  secretion,  and  ex- 
cretion are  obtained  which  have  been  fully  discussed  above. 

Vascular  reaction  is  manifested  by  a  more  or  less  active  filling  of 
the  cutaneous  vessels.  The  ruddy  appearance  of  the  skin  demon- 
strates that  it  owes  its  origin  to  an  enhancement  of  the  normal  resili- 
ency (tone)  of  the  muscular  elastic  fibres  which  control  the  cutaneous 
capillaries.  It  is  also  proved  by  the  rapidity  with  which  blood  flows 
into  a  part  from  which  it  has  been  driven  by  pressure  of  a  finger 
from  a  reacted  spot  as  distinguished  from  the  sluggishness -which  char- 
acterizes its  return  to  an  unreacted  (cyanotic)  part;  in  the  former  the 
endothelial  cells  of  the  capillaries  and  the  cutaneous  muscular  fibres 
are  stimulated  by  the  return  of  arterial  blood,  especially  when  friction 


REACTION.  99 

is  applied ;  in  the  latter  they  are  in  a  state  of  cyanosis  and  partial 
paralysis  which  may  often  be  removed  by  mechanical  excitation  (fric- 
tion). 

That  brief  applications  of  cold  stimulate  the  local  circulation, 
especially  when  aided  by  friction  (which  is  invariably  utilized  in 
combination  with  most  hydriatric  procedures),  is  proved  by  their  value 
in  frost-bites,  which  present  a  true  paretic  hypenemia  of  the  cutaneous 
vessels.*  I  hold  that  this  reaction  is  but  an  increase  of  the  normal 
activity  of  the  arterioles  and  capillaries. 

What  is  the  effect  of  this  local  vascular  reaction  upon  the  heart 
and  larger  vessels?  Again  we  find  the  answer  in  established  physi- 
ological facts,  viz.  :  whatsoever  improves  the  peripheral  circulation 
affects  favorably  the  heart  and  large  vessels,  which  depend  upon  the 
integrity  of  the  former  for  normal  action.  In  abnormal  conditions 
(infectious  fevers,  etc.)  this  interdependence  of  the  peripheral  (cuta- 
neous) circulation  with  the  heart  is  of  enormous  import  in  their  thera- 
peutics, as  will  be  shown. 

The  local  sensory  excitation  and  the  local  vascular  reaction  being 
the  starting-points  of  the  general  reaction,  their  combined  effect  is 
manifested  after  a  more  or  less  lapse  of  time  by  the  phenomenon 
known  as  general  reaction. 

Conditions  Influencing  Reaction. — Reaction  depends  upon  certain 
conditions,  with  which  the  hydrotherapist  must  familiarize  himself  if 
he  would  obtain  the  full  benefits  of  a  cold  procedure :  (a)  Condition 
of  the  patient's  skin;  (6)  locality  and  extent  of  the  surface  treated; 
(c)  duration  of  the  treatment ;  (d)  addition  of  mechanical  or  other 
aid;  (e)  physical  and  psychic  state  of  the  patient;  (/)  stage  of  the 
disease. 

(a)  The  average  temperature  of  the  nude  human  skin  is  in  the 
neighborhood  of  90°  F.  The  difference  'between  the  skin  and  water 
temperature  being  the  chief  element  in  determining  the  reaction  of  the 
patient,  it  is  evident  that  a  water  temperature  near  90°  F.  would  be 
neutral  or  indifferent,  while  a  water  temperature  considerably  below 
90°  would  become  a  decided  thermic  excitant  with  proportionate  reac- 
tion. The  knowledge  of  this  fact  is  utilized  in  arousing  a  fainting 
woman,  and  in  chronic  cases  by  elevating  the  cutaneous  'temperature 
in  hot-air  baths,  in  order  to  increase  the  temperature  difference  be- 
tween the  skin  and  water. 

This  physiologic  fact,  supported  by  positive  clinical  evidence,  en- 

*  In  the  discordant  views  expressed  by  Winternitz,  Mathes,  Martin,  and  others 
the  distinction  between  local  and  general  tonic  action  of  cold  applications  is  not 
drawn  with  sufficient  clearness.  The  differences  in  the  views  advanced  by 
these  writers  may  be  reconciled,  it  is  hoped,  by  the  author's  reconstruction  of 
the  theory  of  reaction. 


100       THE  PRINCIPLES  AND  PRACTICE   OF   HYDROTHERAPY. 

ables  us  to  formulate  the  hydrotherapeutic  law  that :  The  difference  in 
intensity  of  effect  is  in  proportion  to  the  difference  between  t//e  tempera- 
ture of  water  and  skin. 

(b)  The  locality  and  extent  of  the  part  treated  influence  general 
reaction,  not  only  clinically,  but  also  physiologically.     Goldscheider 
has  experimentally  confirmed  what  Charcot  and  others  have  long  ago 
acted  upon  clinically,  viz.,  that  certain  parts  of  the  body  possess  a 
finer  sense  for  cold  than  others;  e.y.,  while  the  back  displays  a  very 
intense  susceptibility  to  cold,  the  vicinity  of  the  spinal  region  is  decid- 
edly less  sensitive  (Charcot  douche).     Moreover,  those  parts  of  the 
cutaneous  surface  which  have  a  better  vascular  supply  offer  a  better 
response  to  cold  (reaction). 

The  extent  of  the  point  of  application  must  of  necessity  become 
a  potent  factor  in  the  subsequent  reaction.  In  health  this  fact  may 
be  noted  in  the  difference  between  the  refreshing  effect  of  a  morning 
cold  ablution  of  the  face  and  that  of  a  plunge  into  a  tub  of  cold  water; 
in  disease  it  is  utilized  when  the  asphyxiated  newborn  is  sprinkled 
with  cold  water  in  mild  cases,  while  in  the  more  intense  cases  the 
entire  body  is  plunged  into  cold  water  to  increase  the  thermic  excita- 
tion and  consequently  the  reaction  which  sets  the  wheels  of  life  into 
motion. 

(c)  That  the  duration  of  the  cold  procedure  is  an  important  element 
in  the  production  of  reaction  is  demonstrated  by  the   physiological 
action  of  cold  upon  the  skin.     A  prolonged  application  of  intense  cold 
(ice-bag  or  coil)  first  drives  the  blood  from  the  arterioles,  and  if  contin- 
ued narrows  them  so  that  they  fail  to  supply  arterial  (bright  red)  blood 
to  the  surface  vessels.     The  result  is  a  cynotic  hue,  indicating  a  passive, 
atonic  state  of  the  local  circulation.     A  brief  or  evanescent  application 
of  ice,  on  the  contrary  (as  with  Hare's  ice  rub),  leaves  the  skin  ruddy 
and  succulent.     Let  any  one  dip  one  hand  into  water  at  40°  F.  for  a 
second,  and  dip  the  other  into  the  same  water  for  a  minute  or  longer; 
in  the  first  case  reaction  will  ensue  on  removal,  the  nails  will  be  pink, 
etc.,  while  in  the  latter  the  hand  will  remain  chilled,  the  nails  will  be- 
come cyanotic,  and  reaction  will  ensue  slowly  in  accordance  with  the 
1  duration.     This  fact  is  utilized  in  beginning  treatment,  i.e.,  before 

the  patient's  reaction  is  ascertained.  In  fevers  and  other  depreciated 
cases,  a  rapid  ablution  at  70°  may  be  of  service,  where  a  full  bath  of 
70°  (Brand)  may  do  irreparable  damage  ;  an  affusion  or  a  cold  dip 
would  be  of  immense  value,  owing  to  their  brevity,  while  a  prolonged 
bath  of  the  same  temperature  would  be  harmful. 

(d)  The  addition  of  mechanical  or  chemic  excitation  may  aid  while 
their  omission  may  mar  reaction.     So  long  as  the  cold  bath  shall  be 
regarded  as  a  temperature-reducing  (antipyretic)  agent  and  be  applied 


REACTION.  101 

without  friction  (I  have  seen  it  so  applied  in  two  of  the  largest  hospi- 
tals in  Germany  in  October,  1902),  its  effect  will  be  disappointing, 
because  the  cold  will  be  made  more  intense  in  order  to  obtain  a  more 
intense  effect,  as  is  done  with  other  remedial  agents.  The  falsity  of 
such  procedure  is  often  the  theme  of  comment  in  these  pages.  How 
many  lives  this  error  has  cost,  and  is  still  claiming,  cannot  be  com- 
puted. Certain  it  is  that  decidedly  cold  baths  have  lost  popularity 
because  they  were  administered  without  mechanical  aid  (friction).  Dr. 
Ball's  candid  confession  on  page  196  may  be  cited  as  an  illustration. 
Chafing  of  the  skin  during  the  bath  stimulates  by  mechanical  excita- 
tion the  sensory  terminals  as  well  as  the  muscular  structures,  surround- 
ing the  cutaneous  vessels,  whose  response  is  made  evident  by  hyperaemia 
of  the  skin.  The  chilling  effect  of  continuous  cold  is  thus  neutralized 
and  the  bath  may  be  given  longer  and  colder  without  depression.  In 
more  depreciated  cases  the  addition  of  Nauheim.  salts,  devised  by 
Mathes,  aids  reaction  materially.  In  chronic  cases  the  douche  fur- 
nishes the  stimulus  of  friction  by  its  pressure;  the  drip  sheet  by  hand 
friction  and  slapping. 

It  is  a  standing  rule  among  my  attendants  and  all  the  nurses  I 
have  trained,  never  to  give  any  cold-water  procedure  without  friction. 
The  wet  pack  is  an  exception;  it  is  applicable  only  in  persons  who 
have  had  their  reaction  trained  by  previous  treatment. 

(e)  The  physical  and  psychic  state  of  the  patient  exerts  more  or 
less  influence  upon  his  reactive  capacity.  An  anaemic  or  otherwise 
depreciated  patient  must  be  managed  with  greater  circumspection, 
because  he  bears  heat  abstraction  badly.  On  the  other  hand,  I  have 
seen  a  robust  member  of  the  Stock  Exchange,  just  from  his  office  and 
depressed  by  his  cares  and  anxieties,  shiver  under  a  circular  douche  of 
90°  F.,  which  a  tender  woman  in  ordinary  health  would  accept  with  in- 
difference. That  patients  suffering  from  alcohol  or  opium  narcosis  re- 
spond badly,  if  at  all,  to  excitation  by  cold  is  a  well-known  fact.  These 
brief  examples  are  cited  to  illustrate  the  principle  that  reaction  depends 
upon  the  integrity  of  the  defensive  powers  of  the  entire  organism. 

(/)  In  the  earlier  stages  of  acute  infectious  diseases,  the  reactive 
response  of  the  organism  is  more  positive  and  reliable  than  in  the 
later  stages,  when  the  central  nervous  system  has  suffered  depreciation, 
from  prolonged  toxaemia  and  the  heart  and  peripheral  circulatior  have 
been  enfeebled.  In  the  latter  stages,  therefore,  more  brief  applica- 
tions of  low  temperatures  with  extra  friction  or  the  addition  of  CO., 
excitation  by  adding  Nauheim  salts  to  the  bath,  become  imperative 
and  are  of  great  value.  Adaptation  of  liydriatric  procedures  to  the 
patient's  reactive  capacity  would  preclude  their  too  frequent  abandon- 
ment as  ineffective  or  deleterious.  Experience  has  also  demonstrated 


102       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

that  in  typhoid  and  other  fevers  the  patient  bears  lower  temperatures 
and  longer  baths  in  the  later  stage  far  better  if  he  has  received  them 
in  the  early  stage.  The  reason  is  obviously  that  the  integrity  of  the 
organism  has  been  maintained. 

In  chronic  cases,  on  the  contrary,  the  system  is  less  capable  of 
responding  to  the  cold,  because  here  the  patient  has  long  been  depre- 
ciated. His  reaction  must  be  developed  by  a  daily  neurovascular 
training,  and  the  treatment  may  be  intensified  in  temperature  and  du- 
ration as  his  reaction  develops  and  improves  with  each  procedure. 

The  proper  gradation  of  cold  procedures  depends  upon  due  regard 
of  the  facts  briefly  set  forth  in  this  chapter.  Inasmuch  as  the  latter 
require  to  be  thoroughly  mastered  and  remembered,  they  will  be  em- 
phasized and  their  significance  frequently  pointed  out  in  connection 
with  the  technique  and  therapeutic  application  of  each  procedure. 


A  TEST  OF  THE  REACTIVE  CAPACITY. 

In  conclusion  the  author  would  call  attention  to  a  crude  test  of  the 
manner  in  which  a  patient  is  likely  to  react  or  fail  to  react  under  cold- 
water  application.  Having  large  clinical  material  under  observation, 
I  have  found  that  the  response  of  the  cutaneous  circulation  to  me- 
chanical excitation  furnishes  an  index  to  the  probable  reactive  capacity 
of  the  patient.  Passing  the  back  of  the  nail  of  the  index  finger  rapidly 
but  gently  across  the  abdomen,  and  increasing  the  pressure  of  the 
nail  with  a  second  stroke  parallel  to  the  first,  induce  a  more  or  less 
deep  reddening  of  the  irritated  skin.  The  rapidity  with  which  the 
red  line  develops  after  the  nail  is  removed  and  the  pressure  required 
to  produce  it  afford  the  trained  eye  a  crude  but  fairly  correct  test  of 
the  patient's  reactive  capacity.  By  applying  this  test  frequently  be- 
fore each  procedure  one  may  readily  train  the  appreciation  of  this  test 
and  thus  avoid  the  necessity  of  slow  development  of  the  reaction  by 
gradual  increase  of  the  intensity  of  the  treatment  which  the  author 
adopts  in  most  cases. 


PART    II. 

CHAPTER   VI. 
THE  PRACTICE   OF   HYDROTHERAPY. 

THE  preceding  chapters  have  been  devoted  to  an  exposition  of  the 
theory  or  principles  underlying  the  application  of  water.  The  effects 
of  the  latter  upon  the  various  systemic  functions  have  been  explained 
as  succinctly  as  is  consistent  with  their  correct  conception.  Mere 
theoretical  quibbling  and  far-fetched  pseudo-scientific  data  have  been 
avoided,  it  being  my  aim  to  lay  down  definite  physiological  data,  ob- 
tained by  experimentation  of  reliable  observers,  as  a  foundation  for 
the  subsequent  chapters  which  shall  deal  with  the  practice  of  hydro- 
therapy. 

The  latter  will  be  divided  into  technical  and  clinical  chapters. 
The  reader  shall  be  fully  familiarized  with  the  most  useful  methods 
of  applying  water  in  disease ;  their  technique  shall  be  clearly  outlined, 
their  rationale  explained,  and  the  chief  clinical  application  of  each  pro- 
cedure shall  be  set  forth,  at  the  risk  of  repetition,  in  subsequent  chapters 
which  will  be  devoted  to  a  discussion  of  some  of  the  diseases  in  which 
hydrotherapy  has  demonstrated  its  value  most  distinctly. 

The  reader  is  urged  to  follow  as  closely  as  possible  the  technique 
described,  and  to  observe  the  effect  of  each  procedure  in  order  that  he 
may  be  enabled  to  modify  it  upon  the  principles  indicated,  whenever 
individual  cases  require  changes  in  technique. 

Familiarity  with  technical  details  is  as  important  to  the  skilful 
and  effective  application  of  water  in  disease  as  it  is  in  the  technique  of 
surgical  procedures. 

The  aim  of  this  work  being  to  render  accessible  to  the  general  prac- 
titioner a  therapeutic  method  of  which  he  has  usually  the  most  vague 
and  imperfect  idea,  the  author  proposes  to  simplify  this  part  of  the 
subject,  the  technique,  by  describing  only  such  procedures  as  his  personal 
experience  as  a  general  practitioner  and  hospital  physician  sanctions  as 
useful. 

The  writings  of  the  hydropaths  abound  in  minute  subdivisions  of 
the  technique,  e.g.,  wrist  baths,  arm  baths,  head  baths,  etc.,  which 


104       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

•will  be  ignored  in  these  pages,  because  their  therapeutic  effect  is  not 
established.  The  procedures  described  in  the  following  pages  will 
enable  the  practitioner  to  execute  every  useful  hydrotherapeutic  indi- 
cation, provided  the  technique  is  followed  with  precision  and  the 
rationale  upon  which  it  is  based  is  thoroughly  mastered. 

Each  procedure  will  be  described  in  detail  and  illustrated  by  draw- 
ings. The  rationale  will  be  next  presented  in  its  true  light,  in  order 
that  the  practitioner  may,  by  fully  acquainting  himself  with  it,  execute 
the  procedure  with  intelligent  regard  for  the  therapeutic  indications  of 
each  case  and  adapt  it  by  modification,  if  need  be,  to  all  exigencies. 

Finally,  the  therapeutic  indications  for  each  procedure  will  be 
enumerated.  The  entire  subject  of  practical  hydrotherapy  will  thus 
be  presented  precisely  in  the  same  manner  as  are  our  medicinal  agents 
in  the  text-books  on  therapeutics. 

ABLUTION. 

This  procedure  is  the  simplest  and  most  universally  applicable  hy 
driatric  application.  The  ablution  is  not  only  useful  in  many  diseased 
conditions,  but  it  also  serves  as  an  introduction  to  more  active  meas- 
ures. It  consists  of  the  application  of  water  by  the  hand,  either  un- 
armed, or  covered  with  a  bath  glove,  or  holding  a  gauze  or  linen  wash 
cloth.  The  sponge  is  to  be  avoided,  because  it  does  not  produce  suffi- 
cient friction  and  thus  prevents  reaction.  The  sponge  is  usually 
squeezed  out  of  water  and  then  passed  by  stroking  over  the  cutaneous 
surface.  In  febrile  conditions  this  would  produce  cooling  by  evapora- 
tion, but  very  little  irritation  of  the  nerve  terminals,  and  consequently 
very  little  if  any  effect  upon  the  central  nervous  system,  which,  as 
has  been  shown,  is  the  chief  aim  of  hydriatric  procedures.  The 
method  and  the  temperature  of  the  water  vary  with  the  object  in  view. 
Several  vessels  filled  with  water  of  proper  temperatures  should  be  within 
reach.  In  acute  febrile  affections,  with  temperature  above  101°  F., 
an  oilcloth  or  rubber  sheet  is  laid  upon  one  side  of  the  bed  covered  with 
a  blanket,  and  upon  this  a  linen  sheet  or  tablecloth  is  spread,  one  half 
reaching  over  the  edge  of  the  bed,  the  ether  rolled  up  on  the  other  side  of 
the  latter.  The  patient  is  now  placed  upon  the  sheet.  His  face  is  first 
bathed  with  water  of  from  65°  to  50°.  Beginning  with  a  temperature 
of  90°  F.  and  on  each  application  reducing  it  two  or  more  degrees,  the 
chest,  the  arms  down  to  the  elbow,  the  back,  the  abdomen,  and  the 
lower  extremities  down  to  the  knees  are  successively  bathed  by  satu- 
rating a  crumpled  piece  of  gauze  or  a  small  towel  with  the  water  and 
gently  rubbing  successive  parts,  frequently  dipping  the  cloth  and 
squeezing  it  out  of  the  water  over  the  parts.  For  the  first  ablution 


THE   PRACTICE   OF   HYDROTHERAPY.  105 

the  washcloth  or  mitten  should  be  well  wrung  out,  so  as  to  obtain  a 
mild  effect,  which  may  be  increased  at  each  ablution  by  allowing  a 
larger  quantity  of  water  to  remain  in  the  cloth. 

The  extremities  are  never  subjected  to  ablution  if  they  remain  cold 
in  fevers,  and  in  cases  having  normal  temperatures  the  extremities 
are  not  treated  at  all,  because  reaction  is  thus  enhanced.  This  is  far 
superior  to  sponging,  which  chills  by  evaporation,  while  the  gentle 
shock  of  the  impact  of  the  water  applied  by  these  methods,  accom- 
panied and  followed  by  gentle  friction,  arouses  the  peripheral  nerves 
and  thus  refreshes  the  entire  system  by  its  reflex  effect.  The  differ- 
ence of  refreshing  effect  arising  from  adding  friction  is  made  evi- 
dent by  comparing  in  the  ordinary  morning  toilet  what  would  be  the 
effect  of  wiping  the  face  with  a  cold  wet  sponge  with  that  of  the  usual 
method  of  dashing  handfuls  of  cold  water  against  the  face  and  using 
friction. 

The  refreshing  and  antifebrile  effect  may  be  enhanced  in  vigorous 
individuals  with  high  temperatures  by  not  drying  the  body  until  the 
ablution  is  complete,  or  by  simply  wrapping  it  in  a  dry  sheet  which 
has  been  kept  in  readiness  on  the  other  side  of  the  bed,  and  allowing 
the  patient  to  dry  spontaneously.  Judgment,  however,  must  be  exer- 
cised to  avoid  chilling,  and  it  must  be  borne  in  mind  that  gentle  reaction 
is  aimed  at,  in  accordance  with  the  principles  enunciated,  and  which  it 
will  be  unnecessary  to  reiterate  in  the  description  of  each  procedure. 

Another  method  for  enhancing  the  antifebrile  effect  is  placing  a 
thin  damp  linen  towel  (always  without  fringes,  to  prevent  dripping) 
successively  over  the  chest,  abdomen,  back,  and  the  upper  parts  of  the 
extremities,  and  throwing  water  upon  them  by  the  hand,  or  from  a 
pitcher,  or  by  squeezing  it  from  a  sponge,  followed  by  friction  with  the 
flat  hand  and  patting  over  the  wet  towel.  This  procedure  approxi- 
mates a  bath,  and  often  accomplishes  qxiite  as  good  results  in  reduction 
of  temperature  and  refreshing  effect  as  the  full  or  half  bath.  By 
modifying  the  temperature  of  the  water  and  length  of  time,  the  anti- 
febrile effect  may  be  modified.  After  the  ablution,  which  may  be  re- 
peated by  going  over  the  body  twice  or  oftener,  the  patient  is  dried. 
It  may  be  repeated  when  the  symptoms  again  demand  it.  In  the  early 
stages  of  all  febrile  affections,  except  pulmonary  and  bronchial,  this 
method  will  found  of  value. 

In  chronic  affections,  too,  the  ablution  is  a  useful  preliminary  to 
the  more  active  hydriatric  procedures.  It  has  long  been  my  custom, 
learned  in  treating  the  desperately  depreciated  patients  presenting 
themselves  at  the  Montefiore  Home,  many  of  whom  have  been  utter 
strangers  to  cold  water  in  health,  to  pursue  the  following  course  : 
The  patient  receives  a  thorough,  warm,  cleansing  bath  with  soap  and 


106        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

flesh  brush.  On  the  following  day  he  is  wrapped,  nude,  in  two 
long-haired  woollen  blankets.  One  blanket  is  spread  on  the  bed, 
the  patient  is  laid  upon  it  with  arms  above  his  head,  and  the  blan- 
ket is  snugly  wrapped  about  the  body  and  between  the  legs.  The 
arms  are  now  placed  alongside  the  body,  and  the  second  blanket  is 
tucked  around  him,  so  that  the  upper  corners  are  firmly  fastened  under 
his  neck  and  the  lower  edge  is  folded  under  his  feet.  He  now  lies 
like  a  mummy  in  the  warm,  room,  more  covers  being  laid  upon  him. 
Sipping  a  glass  or  two  of  ice  water  will  promote  the  action  of  the  skin. 
After  he  has  lain  from  half  an  hour  to  an  hour  and  has  thus  accumu- 
lated heat  upon  the  surface,  the  face  is  bathed  in  water  of  50°.  The 
blankets  are  successively  removed  from  the  chest,  abdomen,  back, 
lower  extremities,  and  arms,  and  these  are  successively  bathed  and 
rubbed  with  water  at  80°  dashed  from  the  hand.  Each  part  is  im- 
mediately dried  and  replaced  under  cover.  The  water  temperature  is 
lowered  two  degrees  daily  until  60°  are  reached.  A  general  dry  rub- 
bing with  a  cloth  or  the  hand  follows,  and  he  then  is  made  to  take 
some  exercise,  if  he  is  able  to  do  so.  Otherwise  he  remains  in  bed 
and  receives  a  cup  of  warm  liquid  food.  This  application  is  best  made 
in  the  early  morning  hours,  but  it  may  be  made  at  any  time,  and 
repeated  as  the  reactive  power  demands,  for  several  days.  During 
the  first  days  the  water  is  applied  by  simply  rubbing  the  hand,  fre- 
quently dipped  in  the  water,  over  the  successive  parts  of  the  body. 
Every  day  a  little  more  Avater  may  be  applied,  the  hollow  of  the  hands 
or  a  pitcher  being  used  for  the  purpose,  and  larger  quantities  are 
applied  in  order  to  educate  or  train  the  patient.  His  reactive  capacity 
is  so  gradually  raised  by  this  method  that  all  shock  is  avoided. 

The  next  step  in  the  hydriatric  training  of  the  patient  is  a  general 
ablution.  The  patient  stands  in  twelve  inches  of  water  at  100°,  and 
is  rapidly  washed  down  with  the  hands,  having  water  at  80°  poured 
upon  him  with  the  hand  or  from  a  vessel,  followed  by  gentle  friction 
just  as  described  above.  The  temperature  is  lowered  each  day  two  or 
more  degrees  until  60°  are  reached.  This  simplification  of  the  meth- 
ods adopted  by  special  hydrotherapists,  like  Fleury,  Winternitz,  and 
Duval,  has  served  me  so  well  that  I  cannot  commend  it  too  highly  in 
health  and  disease,  but  I  must  also  insist  upon  an  exact  technique. 
It  will  not  suffice  to  tell  the  patient,  "  You  must  bathe  in  cold  water 
every  day."  The  importance  of  the  so-called  shock-" surprise"  to  the 
sensory  terminals,  and  the  reaction  following  these  brief  and  succes- 
sive impacts  of  cold  water,  must  be  impressed  upon  him,  and  the  tem- 
perature of  each  day's  ablution  should  be  written  down,  just  as  the 
measure  or  weights  of  medicinal  agents.  It  is  well  to  insist  upon  a 
statement  at  the  next  visit  of  how  the  patient  executed  directions,  in 


THE   PRACTICE   OF   HYDROTHERAPY. 


107 


order  to  correct  faulty  technique.  Most  patients  who  are  able  to  walk 
may  dispense  with  the  dry  pack,  begin  with  a  morning  ablution  of  the 
chest  and  upper  arms,  while  standing  dressed  from  the  waist  down,  in 
front  of  a  basin  containing  water  at  the  prescribed  temperature.  After 
a  week's  daily  ablution  of  the  upper  part  of  the  body,  the  general 
ablution,  while  standing  in  water  at  100°,  may  be  the  next  step  in  the 
neurovascular  training. 

Aside  from  their  therapeutic  effect,  ablutions  are  most  valuable  as 
introductory  to  other  and  more  heroic  hydriatric  procedures,  in  acute  as 
well  as  in  chronic  disease,  inasmuch  as  they  furnish  a  clew  to  the  reactive 
power  of  the  patient.  If,  for  instance,  the  skin  remains  cool  and  pale 
or  becomes  cyanotic  after  ablution  and  friction,  we  are  warned  to  pro- 
ceed cautiously  to  more  intense  procedures.  In  such  cases  only  small  por- 
tions of  the  body  should  be  attacked  each  day  or  twice  a  day,  good  friction 
being  added.  Each  day  the  surface  receiving  ablution  should  be  enlarged. 

This  cautious  proceeding  enables  me  to  assert  that  I  have  never 
seen  a  patient  too  feeble  to  accept  some  form  of  hydrotherapy.  The 
reactive  condition  of  the  patient  is  by  this  gradually  advancing  method 
disclosed  in  chronic  diseases,  the  degree  of  heat  retention  is  indicated, 
and  the  physician  is  enabled  to  adapt  his  subsequent  hydriatric  pro- 
cedures in  accordance  with  observations  thus  made. 

The  rationale  of  the  action  of  ablutions  may  be  found  in  the  peri- 
pheral shock  and  subsequent  stimulus,  which  are  refreshing  because 


FIG.  21.— Fatigue  Curve  of  Right  Hand  after  a  Cold  Ablution.    (See  Normal  Curve,  Fig.  11.) 

they  are  conveyed  to  the  nerve  centres,  and  in  the  dilatation  of  the 
superficial  vessels  by  the  friction,  which,  according  to  Weyrich,  in- 
creases the  evaporation  from  the  skin  fifty  per  cent.  The  latter  must 
be  of  great  value  in  fever,  because,  according  to  Leyden  and  others, 
retention  of  water  is  one  of  the  chief  elements  in  the  febrile  process. 


108       THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

Added  to  this  effect,  we  have  the  dilatation  of  the  superficial  capil- 
laries, as  evidenced  by  the  rosy  hue  of  the  skin  following  ablution 
with  friction.  We  also  have  the  deepening  of  the  inspiration  produced 
by  the  impinging  of  cold  water  upon  successive  parts,  which  im- 
proves the  circulation.  If  the  heart' s  action  is  feeble,  we  may  thus 
enhance  the  tone  in  the  peripheral  vessels  and  facilitate  its  work  by 
removing  the  impediment  to  the  flow  of  blood  in  the  correspondingly 
feeble  cutaneous  vessels.  The  vis  a  f route,  due  to  the  enhanced  resili- 
ency of  the  vessels,  diminishes  the  need  of  a  strong  vis  a  tergo 
upon  the  part  of  the  heart.  This  explains  the  reason  why  ablutions  are 
a  most  valuable  initiatory  procedure,  which  the  feeblest  subjects  may 
bear  with  impunity,  and  which  do  not  alarm  the  patient  and  friends, 
as  do  other  more  heroic  measures. 

Upon  the  muscular  system  ablutions  also  exercise  a  striking  effect. 
The  latter  has  been  beautifully  brought  out  by  Vinaj  and  Maggiora,  as 
noted  on  p.  76.  The  individual  was  sponged  with  water  at  50°  F. 
twice  a  day,  and  the  "  fatigue  curves"  were  taken  before  and  afterward. 
The  latter  are  represented  in  Fig.  21.  This  diagram  graphically  shows 
a  decided  increase  of  muscular  capacity  after  the  cold  ablution,  de- 
monstrating that  its  "  tonic"  effect  is  very  pronounced. 

Therapeutic  Indications. — The  ablution  is  indicated  in  acute  febrile 
diseases  as  an  antifebrile  and  antithermic  agent.  In  mild  cases  of  the 
infectious  fevers  it  may  suffice  to  carry  them  through  their  entire 
course.  I  have  so  treated  cases  of  typhoid  fever  the  temperature  of 
which  did  not  reach  102.5°.  If  the  latter  is  afterwards  exceeded,  the 
ablution  manifests  its  value  as  a  measure  preparatory  to  the  full  cold 
bath. 

In  chronic  cases  the  ablution  is  of  great  value  in  anaemia,  chlorosis, 
phthisis,  etc. 

In  all  those  neurasthenic  cases  which  do  not  require  more  heroic 
measures,  the  ablution  may  be  applied  with  good  effect;  in  the  more 
severe  cases  it  offers  a  gradual  introduction  to  the  douche  and  other 
more  active  procedures. 

THE  HALF-BATH. 

Technique. — A  sufficient  quantity  of  water  to  reach  above  the  pelvis 
of  the  patient  is  poured  into  an  ordinary  bathtub;  the  temperature  of 
the  water,  adapted  to  each  case,  ranging  from  70°  to  85°  F.  After  hav- 
ing a  cold  damp  towel  wrapped  around  his  head,  the  patient  is  placed, 
or  if  not  too  weak  he  seats  himself,  in  the  tub,  which  contains  water  at 
85°  F.  The  attendant  bathes  the  face,  and  begins  at  once  to  rub  the 
back  with  the  left  hand,  while  with  the  right  he  dashes  water  from  a 
small  long-handled  pail  (like  a  milking-pail)  over  the  shoulders  of 
the  patient.  The  latter  at  the  same  time  rubs  the  front  of  his  body 


THE   PRACTICE   OF   HYDROTHERAPY.  109 

•with  both  hands.  Colder  water  is  added  from  vessels  prepared  for  the 
purpose,  until  the  patient  feels  cold.  If  the  teeth  chatter  the  patient 
should  be  removed.  The  continuously  renewed  application  of  the 
water  and  the  successive  shocks  imparted  to  the  body  by  the  moving 
streams  of  water,  accompanied  by  friction,  stimulate  the  peripheral 
nerves  and  dilate  the  superficial  vessels.  Thus  the  entire  organism  is 
refreshed,  the  effect  being  more  intense  than  that  described  under 
"Ablutions."  Especially  important  is  the  absence  of  pressure  from 
the  water,  which  characterizes  the  full  bath,  and  which  would  not 
further  the  dilatation  of  the  surface  vessels  so  much  as  is  done  by  the 
ever-recurring  changes  of  surface  temperature  produced  by  the  tem- 
porary and  repeated  impacts  of  cold  water.  Friction,  too,  is  more 
readily  applied  when  the  body  is  not  submerged.  Hence  the  mechan- 
ical effect,  which  has  been  shown  to  bear  an  important  share  in  most 
hydriatric  procedures,  is  enhanced.  If  the  patient  is  too  weak,  he  may 
lie  in  the  bath  and  refrain  from  washing  himself,  or  he  may  change 
from  the  recumbent  to  the  sitting  position,  being  subjected  to  general 
friction  in  the  former  and  to  drenchings  with  the  pail  in  the  latter. 
The  temperature  of  the  water  should  be  reduced  with  each  bath  in 
order  to  avoid  needless  shock.  It  will  rarely  require  to  be  reduced 
below  70°.  Indeed,  colder  water  would  in  subacute  cases  produce 
painful  sensations  in  the  feet,  which  would  necessitate  removal  of  the 
patient.  The  chief  objection  to  the  half -bath  is,  in  the  author's  opin- 
ion, the  fact  that  the  lower  extremities,  which  possess  the  feeblest 
reactive  power,  are  continuously  immersed  in  the  cold  water,  and  if  not 
subjected  to  friction  are  apt  to  become  chilled  and  painful  with  cramps. 
Therapeutics. — If  the  technique  of  the  half -bath  is  thoroughly 
mastered,  it  may,  according  to  Winternitz,  be  utilized  as  the  most 
universal  hydriatric  procedure  we  have.  In  cases  of  acute  fever,  with- 
out organic  lesion,  it  may  follow  or  take  the  place  of  the  ablutions 
above  described.  The  small  body  of  water  does  not  inspire  the  patient 
with  apprehension ;  the  gradual  and  even  rapid  lowering  of  the  tem- 
perature of  the  water  is  scarcely  perceived,  because  the  agitation  coun- 
teracts the  sudden  cooling  and  friction  promotes  immediate  reaction  of 
each  portion  of  the  body  treated.  As  in  most  fevers,  especially  those 
of  infectious  origin,  the  rise  of  temperature  is  connected  with  and 
partly  due  to  a  paretie  condition  of  the  superficial  vessels,  which 
intercepts  heat  diffusion  from  the  skin,  we  accomplish  one  of  the  chief 
indications  for  temperature  reduction  and  nerve  stimulation  by  the 
widening  of  the  vessels  which  surely  follows  friction  after  the  forcible 
application  of  cold  water.  The  more  slowly  heat  is  abstracted,  the 
more  enduring  will  be  the  lowering  of  the  bodily  temperature.  In 
this  half -bath  we  may  graduate  the  rapidity  of  heat  abstraction  by 


110        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

properly  gauging  the  temperature  of  the  water  and  the  frictions.  But 
the  half-bath,  is  not  so  applicable  for  these  purposes  as  are  other  pro- 
cedures to  be  presently  mentioned.  It  is  rather  as  an  introduction  to 
other  and  more  effective  baths  that  the  bath  here  described  is  useful 
as  an  antifebrile  measure. 

In  chronic  diseases,  after  the  wet  pack  or  other  hand  procedure,  to 
be  referred  to  below,  has  produced  dilatation  of  the  superficial  cuta- 
neous vessels,  the  half -bath  is  a  necessary  sequel  for  the  purpose  of 
maintaining  the  tone  of  those  vessels.  In  these  cases  a  tub  should  be 
filled  to  one-fourth  its  depth,  say  ten  inches,  with  water  of  from  90° 
to  85°  F. ,  which  should  be  actively  set  in  motion  by  the  hands  of  the 
patient  and  attendant,  as  directed  in  the  opening  lines  describing  this 
procedure;  the  duration  should  be  from  six  to  ten  minutes. 

When  the  patient  arises  from  the  half -bath,  a  coarse  linen  sheet, 
previously  warmed  and  kept  in  readiness,  should  be  thrown  around 
him,  and  with  this  he  should  be  rapidly  dried.  In  acute  fevers  the 
drying  should  be  done  in  bed,  a  blanket  and  sheet  having  been  pre- 
viously prepared,  as  directed  above  in  the  case  of  general  ablutions. 

AFFUSION. 

Affusion  is  a  procedure  by  which  the  patient,  sitting  or  standing  in 
an  empty  tub,  or  lying  upon  a  rubber  cot,  receives  upon  his  head, 
shoulders,  and  body  a  stream  of  water  issuing  from  a  bucket,  pitcher, 
or  basin,  preferably  the  former,  because  the  stream  may  be  broader. 
According  to  the  height  from  which  the  water  is  poured  and  the  low 
temperature  (50°  to  65°)  will  be  the  stimulating  effect.  With  feeble 
patients  it  is  well  to  begin  with  higher  temperatures  and  short  dis- 
tances. The  whole  procedure  should  be  rapidly  executed,  the  patient 
being  in  a  sitting  or  semirecumbent  posture  in  acute  conditions,  stand- 
ing in  water  at  100°  in  chronic  cases.  It  is  a  more  energetic  treat- 
ment than  the  ablution,  because  of  its  briefer  duration,  the  increased 
force  of  the  water  impingement,  and  the  larger  surface  treated.  This 
is  the  form  of  cold-water  treatment  which  was  practised  by  Currie 
with  so  much  success  that  it  became  the  basis  of  modern  hydrotherapy. 

Rationale  of  Affusion. — The  action  of  affusions  is  simple.  The 
sudden  impingement  of  a  considerable  volume  of  cold  water,  propelled 
with  decided  force  upon  a  large  surface  of  the  body,  must  produce  an 
intensification  of  those  mechanical  and  thermic  influences  upon  the 
sensory  cutaneous  nerves  which  have  been  discussed  in  detail  above. 
Being  conveyed  to  the  central  nervous  system,  the  reflex  effects  upon 
respiration,  cardiac  action,  assimilation,  and  nutrition  are  decided  and 
unmistakable.  The  intermittent  character  of  the  thermic  and  me- 
chanical irritation  impresses  a  distinct  effect  upon  this  procedure.  It 


THE   PRACTICE   OF   HYDKOTHERAPY.  Ill 

really  presents  a  decided  enhancement  of  all  those  effects  which  have 
been  referred  to  under  the  head  of  ablutions  (page  95;. 

We  are  indebted  to  several  Russian  investigators  for  creditably 
precise  investigations  of  these  effects.  Omitting  the  details,  which 
demonstrate  how  carefully  these  observations  were  made,  a  brief 
resume  may  suffice. 

Blagowetschensky  studied  in  1888  the  effect  of  affusions  upon 
healthy  prisoners  in  solitary  confinement  at  St.  Petersburg.  Affusions 
were  given  morning  and  evening,  from  three  buckets  of  water  of  from 
52°  to  75°. 

Food  and  drink  being  carefully  weighed  and  regulated,  it  was  found 
that  the  assimilation  of  nitrogen  was  increased  in  all  cases,  it  being 
1.43°  after  affusion  of  52°  F.,  and  2.44°  after  affusion  of  75°  F. 
General  assimilation  was  similarly  increased.  Weight  increased  in 
seven  cases — in  a  few  very  considerably — it  decreased  in  one  case. 
Loss  by  cutaneous  and  pulmonary  excretion  was  increased  twenty-four 
per  cent.  The  pulse  was  decidedly  slowed  in  eighty-three  trials,  and 
increased  four  beats  after  two  affusions  of  60°  F.  Respiration  was 
slowed  as  a  whole.  Blood  pressure  was  more  decidedly  increased  after 
the  colder  affusions.  Temperature  was  but  slightly  reduced  in  healthy 
persons.  The  colder  the  affusion,  the  more  the  pulse,  respiration,  and 
temperature  were  affected. 

Therapeutic  Indications.* — There  are  certain  conditions  occurring 
in  acute  diseases  in  which  the  affusion  is  a  most  important  adjunct. 
When  the  patient  is  unconscious  or  delirious,  muttering  or  otherwise ; 
when  he  presents  evidences  of  depreciated  nerve  force  and  general 
adynamia;  when  the  superficial  vessels  react  feebly,  as  manifested  by 
more  or  less  cyanosis,  and  the  heart  is  laboring  to  compensate  for 
their  loss  of  that  elasticity,  which  greatly  aid  the  propulsion  of 
the  blood  in  normal  conditions;  when  the  oronchi  are  loaded  with 
mucus  and  the  air  vesicles  clogged  by  hypostatic  congestion,  no 
remedy  will  arouse  the  failing  powers  like  an  affusion  properly  admin- 
istered. The  patient  may  be  placed  or  held  in  a  semirecumbent  posi- 

*  Dr.  Leopoldt  Senfelder  (Wiener  klinische  Rundschau,  1897)  presents  a 
summary  of  the  uses  to  which  Hippocrates  put  this  procedure,  which  has  his- 
torical interest.  Hippocrates  used  cold  general  affusions  in  syncope  and  col- 
lapse, and  in  tetanus ;  warm  affusions  in  childbed  fever  (instead  of  baths)  and 
in  dropsy.  Partial  affusions  were  applied — warm  to  the  head  in  inflammations 
of  the  eye  ;  cold  to  the  head  in  fever  for  producing  perspiration,  in  insomnia  and 
delirium,  wounds  of  the  head  with  delirium,  bleeding  wounds  elsewhere,  inflam- 
mation of  the  throat.  Hippocrates  also  applied  warm  affusions  to  dislocated  or 
otherwise  injured  joints  for  anodyne  effect,  in  fractures,  in  uterine  displacements, 
in  rectal  fistula  for  cleansing,  in  pains  of  the  thigh,  hips,  and  loins.  He  applied 
cold  affusions  in  diarrhoea  and  collapse,  in  pains  and  swellings  of  joints,  uterine 
displacements,  poured  on  the  thigh  as  a  stimulant,  in  uterine  inflammation  for 
cooling,  and  in  uterine  hemorrhage  as  a  styptic  and  anodyne. 


112        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

tion  in  water  at  a  temperature  of  100°  F.,  while  the  upper  part  of  the 
body  is  douched  and  dried  with  friction,  with  water  at  60°  to  85°  F. 
or  lower,  for  two  or  more  seconds,  cautiously  observing  effect,  and 
repeating  in  an  hour  or  less  frequently,  until  result  is  obtained. 
The  refreshing  effect  of  such  a  bath  judiciously  given  will  never  be 
forgotten  by  any  one  who  has  once  witnessed  it.  The  patient  who 
entered  the  tub  with  muttering  delirium  is  often  aroused  to  conscious- 
ness, the  eye  brightening  and  the  countenance  losing  its  apathetic  ap- 
pearance. Others,  whose  respirations  were  shallow  before  the  bath, 
are  often  made  to  breathe  deeply,  cough,  and  expectorate  freely,  and 
return  to  bed  with  lungs  freed  from  threatening  hypostasis.  In  others 
again,  whose  cyanotic  or  marbled  skin  indicated  heart  failure,  the  sur- 
face becomes  ruddier,  a  more  active  cutaneous  circulation  ensues,  and 
the  pulse  gains  in  force  and  diminishes  in  frequency.  The  reflex  effect 
upon  the  phrenic  deepens  the  inspiration,  a  fresh  supply  of  oxygen  is 
carried  to  the  feebly  expanding  lungs,  the  heart  is  aroused,  and  hypo- 
static  embarrassment  is  overcome.  The  whole  aspect  of  the  case  is 
often  changed  by  these  brief  applications  of  cold  to  the  surface,  fol- 
lowed by  rapid  drying.  Now  stimulants  which  had  failed  to  arouse 
the  flagging  powers  act  more  efficiently,  their  effect  being  more  endur- 
ing. The  testimony  of  that  experienced  clinician,  Winternitz,  which 
has  been  confirmed  repeatedly,  should  be  borne  in  mind,  when  this 
terrible  collapse  condition  menaces  life.  "Collapse,"  says  he,  "is 
almost  universally  regarded  as  a  contraindication  to  every  application 
of  cold.  I  would  again  express  the  opinion  that  I  know  no  more 
powerful  or  effective  agent  for  combating  threatening  or  existing  col- 
lapse than  the  intense  and  intelligently  applied  excitation  by  cold. 
How  often  have  I  seen,  in  advanced  fever  processes,  in  degenerated 
typhoids,  a  rapidly  favorable  change  wrought  in  the  corpse-like  cold- 
ness of  the  extremities  in  the  most  serious  manifestations  of  nerve 
adynamia,  in  the  hypostatic  congestion  of  lungs,  by  one  dipping  into 
a  very  cold  bath,  or  one  cold  application.  I  am  firmly  convinced  that 
very  often  these  manifestations  are  not  due  to  heart  feebleness,  but  to 
a  collapse  of  the  vessels,  and  here  an  evanescent  but  energetic  excita- 
tion by  cold  is  the  only  reliable  remedy,  as  I  have  repeatedly  proved." 

Henoch  *  speaks  highly  of  cold  as  a  stimulant  in  collapse  of  chil- 
dren's maladies.  He  advises  a  half-bath  (91°  F.),  with  cold  affusion 
over  the  neck  and  chest. 

Affusion  is  also  the  method  by  Avhich  Currie  made  his  remarkable 
cures  in  typhus  fever,  using  chiefly  sea  water  on  board  ship.  Pie 
placed  the  patient  upon  the  deck  and  poured  bucket  after  bucket  of 
*  Deutsche  Mediziiial-Zeitung,  September  1st,  1890. 


THE   PRACTICE   OF   HYDROTHERAPY.  113 

sea  water  upon  his  burning  body,  with  the  result  of  completely  chang- 
ing the  aspect  of  the  cases. 

Professor  Hoffmann,  of  Leipzig,*  says :  "The  greatest  benefit  has 
been  obtained  from  the  use  of  cold  rubbings  and  douches  in  diseases  of 
the  lungs.  No  injurious  results  have  ensued  from  their  intelligent 
application.  It  is  well  known  how  cold  affusions  over  the  chest  and 
neck  produce  quite  peculiarly  energetic  inspiratory  movements.  Hence 
they  have  long  been  used  to  deepen  the  breathing  in  somnolent  pa- 
tients. Fever  patients  who  respire  superficially  and  thus  favor  the 
production  of  hypostasis  may  be  protected  against  dangerous  com- 
plications. Deeper  inspiration  is  produced,  which  furthers  the  circula- 
tion from  the  right  to  the  left  heart,  and  which  results  in  a  dilatation 
of  the  cutaneous  vessels  and  in  a  proportional  anaemia  of  the  inner 
organs." 

In  scarlatina,  when  the  system  is  overwhelmed  by  the  poison,  the 
circulation  embarrassed,  the  skin  pale  or  marbled  or  cyanotic,  the  res- 
piration shallow,  the  temperature  high,  the  pulse  rapid  and  feeble, 
truly  marvellous  results  may  be  obtained  by  the  judicious  use  of  brief 
affusions.  Reaction  occurs  rapidly,  and  with  it  comes  an  improved 
peripheral  and  general  circulation,  deepened  inspiration,  brightened 
countenance,  and  roseate  skin.  Let  not  the  fear  of  cold  deter  any  one 
from  resorting  to  cold  affusions  (70°  to  60°  F.)  in  these  desperate  cases. 
They  are  the  hy driatric  substitute  for  digitalis  and  alcohol ;  from  them 
the  enfeebled  heart  will  obtain  vigor  and  refreshment,  sending  the  life 
blood  in  joyous  currents  through  the  sluggish  arteries,  removing  liypo- 
stasis,  delirium,  stupor,  and  preventing  fatal  issues  in  the  most  des- 
perate conditions.  I  say  this  from  conviction,  born  of  clinical  obser- 
vation. But  judgment  is  required  in  adapting  temperature,  duration, 
quantity  of  water,  and  force  of  impact  to  the  condition  of  the  patient. 

Delirium  Tremens. — Sir  William  Eroadbent  f  lauds  affusion  with 
ice-cold  water  as  productive  of  immediate  favorable  results  in  this  dis- 
ease. The  patient,  being  stripped  and  lying  on  a  blanket  spread  upon 
a  waterproof  sheet,  is  treated  with  copious  and  rapid  dashes  of  ice 
water  on  a  large  sponge,  upon  face,  chest,  and  body;  he  is  rubbed  dry; 
the  back  is  subjected  to  the  same  treatment,  which  is  done  two  or  three 
times  in  succession,  vigorous  friction  being  applied  between  the  affu- 
sions. Sound  refreshing  sleep  and  speedy  recovery  are  claimed  even 
when  pneumonia  and  albuminuria  were  complications  which  precluded 
opiates.  While  the  author  has  had  no  personal  experience  with  this 
method,  he  would  Avarmly  advise  it  on  the  ground  of  the  physiological 
action  of  evanescent  cold  upon  the  cutaneous  vessels,  which  in  alco- 

*  "  Vorlesimgen  iiber  allgemeine  Therapie,"  Leipzig,  1892. 
f  British  Medical  Journal,  July,  1905. 
8 


114       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

holic  saturation  are  dilated  and  in  a  semiparetic  condition,  as  evi- 
denced by  cyanosis.  A  deepened  inspiration,  too,  enhances  oxygena- 
tion  and  furthers  elimination  from  the  alcohol-clogged  system. 

Meningitis  and  Other  Cerebral  Disturbances. — Rohrer  *  reports  fif- 
teen noteworthy  because  desperate  cases  in  which  cold  affusions  demon- 
strated their  life-saving  value.  After  remonstrating  against  the  ten- 
dency of  physicians  to  yield  to  lay  prejudice  when  they  are  themselves 
convinced  of  the  therapeutic  value  of  cold  water  in  fevers,  he  states 
that  he  found  cold  affusions  of  great  service:  "1.  In  cerebral  manifes- 
tations consequent  upon  high  temperatures  in  infectious  diseases  (five 
cases).  2.  In  meningitis;  disturbance  of  cerebral  functions  by  patho- 
logical changes  in  the  central  nervous  system ;  hypersemia,  exudation, 
infiltrations  by  neoplasms;  insolation;  simple  and  tuberculous  menin- 
gitis (six  cases).  3.  In  meningeal  symptoms  in  acute  non-infectious 
diseases,  especially  pneumonia  cerebralis  (four  cases) . "  The  histories, 
given  in  complete  form,  illustrate  the  correctness  of  this  author's  views, 
which  he  summarizes  as  follows: 

"  These  cold  affusions  act : 

"1.  As  temperature-reducing  agents,  when  they  are  made  very 
cold  and  prolonged  up  to  ten  buckets. 

"  2.  Antispasmodic,  calming  in  tonic  and  clonic  convulsive  condi- 
tions resulting  from  cerebral  irritation. 

"  3.  Derivate,  poured  upon  the  skin  of  the  head  and  neck ;  the  skin 
is  always  reddened  intensely. 

"  4.  Irritant  to  the  peripheral  nerve  endings,  producing  deep  inspi- 
rations. 

"  These  affusions  are  applicable : 

"  (a)  In  all  febrile  conditions  accompanied  by  manifestations  of 
cerebral  hypersemia  or  irritation. 

"  (6)  In  meningitis,  regardless  of  its  etiology. 

"  (c)  IB  very  high  temperatures  with  cerebral  disturbance. 

"  (d )   In  infections  with  sopor,  coma,  f uribund  delirium. 

"  (e)  In  disturbance  of  circulation  in  the  left  ventricle,  as  a  sequel 
of  insufficient  respiration,  hypostasis,  croupous  pneumonia." 

This  practical  physician's  clearly  stated  views,  being  sustained  by 
full  clinical  histories,  are  entitled  to  careful  consideration.  They  are 
here  recited,  in  order  that  his  observations  may  serve  the  reader  in  an 
emergency  in  these  almost  hopeless  cases. 

In  chronic  diseases  the  affusion  is  an  excellent  substitute  for  the 
douche,  if  it  is  administered  with  care  and  precision  as  to  temperature 
and  the  patient's  reactive  capacity.  It  is  therefore  a  valuable  agent 
in  domestic  practice. 

*Deutsches  Archiv  fQr  klinische  Medicin,  1874,  No.  13. 


THE   PRACTICE    OF   HYDROTHERAPY.  115 

The  prejudice  existing  in  the  lay  mind  against  pouring  a  basin  or 
bucket,  or  pitcher  of  cold  water  over  a  fever  patient  will  disappear 
very  quickly  if  the  friends  or  relatives  be  not  permitted  to  witness  the 
procedure,  but  allowed  only  to  observe  the  change  wrought  by  it  in  the 
delirious  or  unconscious  patient. 

THE  SHEET  BATH. 

Technique. — One  side  of  the  patient's  bed  or  an  adjoining  cot  is 
protected  by  a  rubber  sheet.  A  blanket  is  spread  upon  the  latter. 
Several  linen  sheets,  coarse  or  fine,  according  to  the  effect  desired  (see 
Rationale),  a  basin,  a  bucket  of  water  of  the  required  temperature,  a 
cup,  and  a  sponge  are  placed  upon  a  chair.  The  sheet,  being  partly 
wrung  out  of  water  of  from  50°  to  80°  F.,  according  to  the  effect  aimed 
at,  is  spread  upon  the  bed  as  rapidly  as  possible  to  prevent  a  change  of  its 
temperature.  The  head  and  face  of  the  patient  having  been  bathed 
with  ice  water  and  a  wet  turban  wrapped  around  his  head,  he  is  laid 
upon  the  wet  sheet  and  is  wrapped  with  it  in  the  following  manner : 
The  patient  is  directed  to  hold  both  arms  above  his  head.  The  upper 
left  border  of  the  sheet  is  now  brought  close  under  the  left  axilla  and 
laid  across  the  front  of  the  chest,  reaching  beyond  the  axillary  line  of 
the  right  side ;  the  lower  portion  is  placed  over  the  pelvis  and  the  edge 
tucked  in  between  the  lower  extremities.  The  arms  are  brought  down 
and  placed  alongside  the  body,  from  which  they  are  separated  by  the 
intervening  sheet.  Now  the  right  portion  of  the  sheet  is  carried 
across  the  body  above  and  below,  enveloping  the  arms  and  shoulders 
as  well  as  the  lower  extremities.  The  right  upper  border  of  the  sheet 
is  firmly  drawn  over  the  left  shoulder  and  securely  tucked  under  the 
latter ;  the  lower  end  is  tucked  underneath  the  heels.  In  this  manner 
the  patient  is  snugly  enveloped  in  the  wet  sheet  and  no  uncovered  parts 
of  the  body  lie  in  apposition.  The  arms  may,  in  feeble  patients,  be 
left  out  altogether,  and  simply  bathed  during  the  process.  This  will 
also  facilitate  the  application  of  the  sheet.  The  first  impression  will 
be  a  shock  to  the  peripheral  nerves,  caused  by  the  sudden  contact 
with  the  cold  wet  sheet.  A  deep  gasping  inspiration  and  a  little 
shivering  follow.  These  are  readily  overcome  by  the  patient's  own 
high  temperature,  and  their  removal  is  now  aided  by  the  manipulations 
of  the  bath  nurse,  who,  with  outstretched  hands,  gently  but  firmly  and 
gradually  sweeps  over  the  wet  sheet,  passing  over  the  entire  boQy  suc- 
cessively. Small  portions  of  the  body  should  then  be  rubbed  in  this 
manner  until  they  warm  up.  So  soon  as  any  part  of  the  body  becomes 
thoroughly  warmed,  water  from  50°  to  60°,  according  to  the  condition 
of  the  patient,  is  poured  from  a  cup  or  squeezed  from  a  sponge  over  it, 


116        THE   PRINCIPLES   AND   PRACTICE   OF    HYDRO-THERAPY. 

and  rubbing  is  resumed.  When  the  treated  part  ceases  to  warm  under 
friction,  the  attendant  proceeds  to  another  part.  These  gentle  but  firm 
passes  or  frictions  over  successive  parts  of  the  body  are  alternated  with 
the  pouring  on  of  small  quantities  of  cold  water,  until  the  entire  body 
feels  cooled  or  the  patient  shivers.  Rigor  and  chattering  of  the  teeth 
must  always  be  avoided,  because  they  are  an  evidence  of  muscular  con- 
traction, and  of  a  too  decided  temperature  difference  between  the  cen- 
tral and  peripheral  portions  of  the  body,  which  causes  the  former  to 
rise  and  thus  counterbalance  the  effect.  Friction  prevents  this  ob- 
jectionable feature  of  all  cold  baths  and  enables  us  by  the  renewed 
application  of  cold  water  upon  the  warm  parts  of  the  sheet  to  maintain 
the  cooling  effect.  After  its  termination,  the  patient  is  rapidly  dried, 
the  sheets  and  blankets  and  rubber  sheet  are  withdrawn  by  rolling  him 
upon  his  side,  and  without  disturbance.  It  is  not  necessary  to  apply 
friction  in  drying,  except  to  the  extremities.  We  have  in  the  sheet 
bath  an  admirable  antifebrile  procedure,  the  effect  of  which  may  be 
greatly  enhanced  by  allowing  the  patient  to  remain  in  it,  leaving  him, 
without  drying  at  all,  packed  snugly  in  the  blanket  and  wet  sheet  for 
half  an  hour.  Its  mildness,  as  compared  with  the  full  cold  baths,  ren- 
ders it  more  acceptable  to  the  patient  and  his  friends,  and  it  may  thus 
be  utilized  as  a  valuable  initiatory  measure,  intermediate  between  the 
ablution  and  the  half-bath,  which  have  been  discussed. 

Therapeutic  Indications. — The  sheet  bath  is  applicable  in  all  acute 
diseases  in  which  an  elevated  temperature  is  a  leading  manifestation. 
I  have  used  it  as  a  valuable  substitute  for  the  full  bath,  when  the  nec- 
essary apparatus  for  the  latter  could  not  be  procured.  For  instance, 
in  the  country  or  in  tenement  houses,  where  bathtubs  are  not  obtainable, 
linen  sheets,  or  at  least  linen  tablecloths  (or  even  old  and  well-worn 
cotton  sheets),  a  piece  of  oilcloth,  a  blanket,  to  protect  the  bed,  a 
bucket  of  water,  and  a  sponge  are  all  that  are  needed.  In  the  most 
humble  home  an  ironing-board  or  a  small  door  may  be  used  in  lieu 
of  bed  or  sofa.  By  laying  the  upper  edge  of  the  board  upon  a  box? 
or  stool,  or  using  the  floor,  laying  an  oilcloth  upon  the  board  or 
floor,  a  piece  of  bagging  or  a  comforter  over  this,  and  saturating 
a  tablecloth  or  even  a  cotton  sheet,  the  sheet  bath  may  be  given 
with  an  abundance  of  water  from  a  sponge  or  pitcher.  The  super- 
fluous water  running  from  the  body  may  readily  be  kept  from  flood- 
ing the  floor  by  careful  mopping  with  cloths  or  with  a  sponge,  from 
which  it  may  be  squeezed  into  a  bucket.  It  should  always  be  borne  in 
mind  that  a  patient  with  a  temperature  of  103°  and  over  is  not  in 
danger  of  taking  cold.  This  bugbear  often  prejudices  the  physicuan 
as  well  as  the  patient  against  all  hydriatric  measures,  and  especially 
those  which  require  the  use  of  abundant  quantities  of  cold  water. 


THE   PRACTICE   OF   HYDROTHERAPY.  117 

To  enhance  the  antipyretic  and  soothing  effect  of  this  treatment  in 
a  tenement  house  or  in  the  country,  the  patient  should  be  removed  to 
the  bed,  wrapped  snugly  in  the  wet  sheet  and  blanket,  and  allowed  to 
remain  quiet  for  half  an  hour.  Most  frequently  he  will  fall  into  a 
gentle  slumber,  from  which  he  should  not  be  aroused  for  any  pur- 
pose. Prolonged  shivering  demands  immediate  removal  and  drying. 

The  antipyretic  action  of  the  sheet  bath  may  be  explained  as  follows : 
The  immediate  effect  upon  the  peripheral  vessels  is  to  contract  them, 
render  the  skin  ansemic  and  pallid,  and  drive  the  blood  from  the  cuta- 
neous surface  toward  the  interior.  For  this  reason  a  wet  bandage  and 
occasional  affusions  upon  the  head  are  necessary  to  prevent  retrostasis 
with  determination  of  blood  to  the  head.  Since,  however,  the  shock  to 
the  sensory  nerves  is  brief,  and  no  sooner  is  conveyed  to  the  nerve 
centres  than  it  is  reflected  by  the  motor  tracts,  the  local  action  is  really 
evanescent.  The  sheet  rapidly  warms  up  if  the  patient's  temperature 
is  above  102°.  The  pouring  of  cold  water  upon  the  warmed  parts  of 
the  sheet  abstracts  heat  from  the  blood  in  the  cutaneous  vessels,  whose 
lumina  have  been  increased  by  the  frictions  referred  to.  In  this  man- 
ner a  gradual  cooling  off  and  reheating  of  the  sheet  ensue,  which  are 
conveyed  from  and  to  the  parts  beneath  it.  Each  time  the  cold  water 
impinges  upon  the  sheet  a  deepened  inspiration  ensues,  which  fur- 
nishes more  oxygen.  The  enhanced  tone  of  the  peripheral  vessels  re- 
moves the  previously  existing  abnormal  condition  of  the  blood  pressure, 
and  thus  gives  the  heart  freer  action,  reducing  the  pulse  rate,  and,  if 
the  patient  be  allowed  to  rest  in  the  wet  sheet,  a  calm  sleep  ensues,  the 
result  being  cooling  and  refreshment,  accompanied  by  slight  exhaus- 
tion due  to  the  mechanical  irritation.  A  rational  antifebrile  effect  is 
thus  inaugurated,  which  does  not  fatigue  the  patient  so  much  as  the 
full  bath,  and  which  is  more  readily  accepted  by  him  and  his  friends 
than  the  latter. 

This  practical  and  ingenious  method  of  applying  water  is  exceed- 
ingly useful  as  a  means  of  refreshing  the  nervous  system  of  patients 
who,  by  reason  of  feebleness  in  acute  or  chronic  diseases,  are  unable 
to  accept  other  and  more  heroic  methods. 

By  modifying  the  sheet  bath  a  more  stimulating  procedure  may  be 
obtained,  which  is  well  adapted  for  chronic  diseases  in  which  abstrac- 
tion of  heat  is  not  required  or  is  entirely  contraindicated.  This  is  the 
"  kalte  Abreibung "  so  much  in  vogue  among  the  Germans  described 
elsewhere. 

The  sheet  bath  differs  somewhat  in  chronic  cases,  since  the  larger 
proportion  of  these  patients  may  be  treated  in  a  standing  position, 
which  gives  the  attendant  free  scope  for  more  vigorous  friction.  This 
is  called  the  drip  sheet. 


118        THE   PRINCIPLES    AND    PRACTICE   OF   HYDROTHEEAPY. 

DRIP  SHEET. 

In  the  Montefiove  Home  for  chronic  diseases,  which  is  really  an 
institution  for  incurables,  receiving  only  the  most  desperate  types  of 
all  chronic  diseases,  organic  and  functional,  the  sheet  bath  was  used 
by  the  author  in  the  form  called  " drip  sheet"  for  several  years  prior 
to  the  construction  of  a  douche  apparatus.  Having  proved  satisfac- 
tory, the  procedure  as  there  pursued  may  serve  as  a  guide  for  its  exe- 
cution in  private  practice. 


Fia.  22.  —Drip  Sheet.    First  position.    Photographed  by  Dr.  Kossman. 


Technique  of  the  Drip  Sheet. — The  temperature  of  the  room  should 
not  be  less  than  70°.  The  patient  stands  in  a  foot  or  bath  tub  con- 
taining twelve  inches  of  water  at  100°  F.,  to  prevent  chilling;  a  sheet 
dipped  in  water  at  80° — daily  or  less  frequently  reduced  until  it  reaches 
60° — is  placed  dripping  over  his  shoulders  and  back  in  the  following 
manner.  The  left  upper  border  of  the  sheet  is  held  by  the  left  hand, 
while  the  right  hand  gathers  the  right  border  into  folds.  The  sheet 


THE   PRACTICE   OF   HYDROTHERAPY. 


119 


is  now  dipped  into  a  bucket  of  water,  from  which  it  is  taken  dripping 
and  applied  under  the  right  axilla  of  the  patient,  as  shown  in  Fig.  22. 
Pressing  the  sheet  firmly  to  his  side  with  the  right  arm  (Fig.  23)  the 
patient  is  directed  to  turn  and  thus  envelop  himself  in  the  wet  sheet 
(Fig.  24),  the  attendant  drawing  upon  the  wet  sheet  at  the  same  time  to 
insure  its  snug  clinging  to  the  body.  When  the  entire  body  is  thus  cov- 
ered, the  upper  border  of  the  sheet  is  tucked  in  around  the  neck,  and  the 
lower  border  is  wrapped  around  the  legs.  The  attendant  now  makes 
rapid  passes  over  the  sheet  up  and  down  the  back,  sides,  and  lower  ex- 
tremities with  the  outstretched  hand  (Fig.  25),  occasionally  slapping  the 
surface  to  increase  mechanical  irritation.  A  basin  of  water  from  ten  to  fif- 
teen degrees  below  the  temperature  of  the  sheet  water  is  poured  over  the 


FIG.  23.— Drip  Sheet.     Second  position. 

head  and  shoulders  two  or  three  times  at  short  intervals.  This  is 
alternated  with  frictions  for  from  five  to  ten  minutes.  The  sheet  is 
now  rapidly  withdrawn.  In  most  cases,  especially  after  the  treat- 
ment has  been  pursued  for  some  time,  the  skin  becomes  decidedly 
hypersemic.  The  patient  now  steps  upon  a  woollen  rug  or  blanket, 
and  is  thoroughly  dried  with  soft  linen  towels.  This  is  followed  by 


120        THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

friction  with  a  warm  sheet  or  towel,  which  increases  the  cutaneous  suf- 
fusion. The  patient  emerges  from  this  bath,  during  the  first  few  days, 
somewhat  fatigued  but  refreshed.  If  the  fatigue  is  decided,  the  pro- 
cedure should  be  shortened  until  the  patient  evinces  more  resisting 
and  reactive  capacity.  Usually  he  is  able  to  walk  out,  which  is  a 
great  advantage.  In  good  weather  a  gentle  promenade  after  the  treat- 
ment is  a  sine  qua  non,  because  the  respiration  is  deepened  and  more 
oxygen  may  thus  be  made  to  enter  the  lungs. 

The  rationale  of  the  drip  sheet  may  be  explained  upon  the  same 
principles  which  govern  other  similar  procedures.  As  the  wet  sheet 
envelops  the  entire  surface  of  the  body,  the  thermic  irritation  is  more 
pronounced  than  it  is  from  an  ablution.  It  stimulates  the  cutaneous 


FIG.  24.— Drip  Sheet.     Patient  turning. 

vessels  and  the  muscular  structures  of  the  skin  also  to  contract  for  a 
brief  time,  and  to  dilate  just  as  quickly  and  completely.  The  fric- 
tions made  by  the  rapid  to-and-fro  passage  and  pressure  of  the  flat 
hand  over  separate  portions  of  the  sheet-covered  body  greatly  enhance 


THE   PRACTICE   OF   IIYDROTHERAPY.  121 

the  reactive  dilatation  of  the  cutaneous  vessels.  A  large  quantity  of 
blood  is  thus  drawn  from  the  interior  to  the  general  surface. 

Physiological  investigations  having  shown  that  two-thirds  of  the 
entire  blood  quantum  may  find  lodgement  in  the  skin,  the  enormous 
derivative  effect  of  a  good  sheet  bath  becomes  evident. 

The  repetition  of  the  thermic  irritation  incident  to  the  renewed 
pouring  of  cold  water  upon  those  parts  of  the  body  which  have  been 
warmed  by  friction  of  the  attendant's  hands  affords  a  renewal  of  all 
these  results,  which  in  chronic  cases  produce  tonic,  and  in  acute  cases 
antifebrile  effects  of  unmistakable  value. 

Interesting  practical  observations  on  the  effect  of  the  drip  sheet 
have  been  published  by  Dr.  Storoscheff,  of  Moscow.*  Examination 
during  the  process  showed  more  or  less  warming  of  the  skin,  which 
sometimes  was  so  pronounced  as  to  cause  vapor  to  rise  from  the  sheet. 


FIG.  25.— Drip  Sheet.    Friction. 

This,  doubtless,  arose  from  the  influx  of  blood  to  the  dilated  cutaneous 
vessels. 

The  respiration  was  at  first  deepened  after  a  gasp,  and  then  in- 
creased.    In  fifty  drip  sheets  given  to  sixteen  hospital  nurses,  ages 
*  Blatter  fur  klinische  Hydrotherapie,  Nos.  1  and  2.  1894. 


122        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

from  twenty-one  to  twenty-four  years,  Gritzay  found  the  respiration 
lowered  in  thirty-two,  unchanged  in  nine,  and  increased  in  three.  The 
force  was  ascertained  by  Waldenburg's  pneuraatometer.  Respiration 
was  increased  forty-five  times,  and  unchanged  five  times ;  expiration 
was  increased  thirty-three  times,  unchanged  thirteen  times,  and  dimin- 
ished four  times,  the  increase  averaging  fourteen  millimetres.  The 
average  increase  of  inspiration  exceeded  that  of  expiration. 

The  number  of  heart  beats  was  generally  diminished ;  the  blood 
pressure  was  increased  thirteen  times,  unchanged  sixteen  times,  and 
diminished  only  three  times.  The  average  increase  of  blood  pressure 
was  eight  millimetres. 

The  rectal  temperature  was  diminished  in  all  cases. 

The  muscular  capacity,  ascertained  in  the  upper  extremities  by 
Berg's  dynamometer,  was  increased  3.5  kgm.,  as  an  average.  Pletys- 
mographic  tracings  showed  much  lower  waves  with  slanting  excursions 
and  modified  secondary  waves,  the  reflux  waves  becoming  less  distinct. 

Feit  gives  the  result  of  experiments  made  to  ascertain  the  effect  of 
drip  sheets  upon  nitrogen  consumption  and  assimilation  of  the  nitro- 
genized  constituents  of  food  in  four  students,  aged  from  twenty-three 
to  twenty-five  years,  who,  during  a  period  of  twenty-one  days  were 
under  close  observation.  The  method  employed,  food  given,  etc.,  are 
stated  in  detail.  The  treatment  was  given  morning  and  evening.  In 
all  these  cases  the  nitrogen  consumption  was  increased,  the  maximum 
being  thirty-one  per  cent,  the  minimum  one  per  cent.  Assimilation 
of  nitrogenous  materials  was  improved  in  all  instances;  the  appetite 
increased  in  three  cases  and  diminished  in  one  case.  The  pulse  be- 
came slower,  and  remained  so  for  an  hour ;  the  respiration  was  deep- 
ened, but  there  was  an  average  increase. 

The  vital  capacity,  studied  in  five  women  after  a  drip  sheet  of  54°, 
was  increased  by  from  three  hundred  to  fifteen  hundred  kilograms ;  an 
increase  of  from  one  hundred  to  one  thousand  kilograms  remained  for 
an  hour  in  four  cases  out  of  five. 

In  1890  Everneeff  observed  carefully  the  influence  of  the  drip  sheet 
upon  the  assimilation  of  fats  in  healthy  persons  from  nineteen  to 
twenty-nine  years  of  age.  Although  the  appetite  was  increased,  there 
was  no  noticeable  change  in  the  assimilation  of  fats,  judged  by  the 
excretion  of  fatty  acids,  etc. 

Therapeutic  Indications. — There  are  many  chronic  ailments  to  which 
the  drip  sheet  is  applicable,  especially  as  a  substitute  for  the  douche, 
which  can  be  had  only  in  institutions,  viz. :  as  a  tonic  in  chlorosis, 
anaemia,  and  neurasthenia;  as  a  derivative  in  intestinal  catarrhs;  as  a 
revulsive  and  alterative  in  melancholia,  hypochondriasis,  neuralgias; 
and  in  pulmonary  and  bronchial  diseases. 


THE   PRACTICE   OF   HYDROTHERAPY.  123 

The  flexibility  and  simplicity  of  the  method  commend  it  especially. 
It  is  probably  the  most  flexible  hydriatric  measure  known.  By  wring- 
ing the  sheet  well  out,  or  by  using  a  coarser  sheet  or  a  lower  temper- 
ature or  a  shorter  time,  or  by  slapping  with  instead  of  simply  press- 
ing the  outstretched  hand  over  the  wet  sheet,  the  local  excitation 
of  the  cutaneous  nerves  and  vessels  will  be  enhanced  just  to  the  extent 
which  the  judgment  of  the  practitioner  may  deem  requisite.  By  satu- 
rating it  with  more  water  the  antipyretic  effect  is  increased,  which 
may  be  still  more  intensified  by  more  prolonged  application  and  more 
frequent  addition  of  colder  water,  or  by  a  finer  texture  of  the  sheet. 
The  duration  of  the  sheet  bath  is  a  matter  for  the  most  careful  discrimi- 
nation. Two  to  five  minutes  suffice  in  most  cases  for  the  tonic  effect, 
while  for  the  antipyretic  effect  fifteen  to  twenty  minutes  may  be  neces- 
sary. It  is,  of  course,  understood  that  the  excessive  sensitiveness  of 
the  skin  in  the  presence  of  cutaneous  diseases,  or  any  extensive  in- 
flamed surface,  preclude  the  use  of  the  sheet  bath  entirely. 

In  the  care  and  judgment  necessary  in  adapting  the  sheet  bath,  as 
most  other  hydriatric  procedures,  to  various  conditions,  must  be  sought 
the  reason  why  the  best-informed  medical  men  in  France  and  Germany 
send  their  chronic  cases  which  have  resisted  simple  measures  to  col- 
leagues who  have  made  a  special  study  of  hydrotherapy,  and  consign 
them  to  their  treatment  entirely.  A  large  experience  enables  these 
gentlemen  to  adapt,  by  infinite  variations,  seemingly  slight  to  the  un- 
initiated, certain  modifications  which  promote  recovery  after  less  intel- 
ligently applied  hydriatric  measures  have  sometimes  failed. 

I  do  not  desire  to  be  understood,  however,  that  the  general  prac- 
titioner is  not  perfectly  competent  to  treat  such  cases  hydriatically. 
On  the  contrary,  it  is  the  aim  of  this  work  to  lend  him  such  assistance 
as  may  enable  him  to  treat  his  patients  at  home,  and  to  discover  the 
limitations  of  domestic  treatment,  for  many  cases  are  needlessly  sent 
away  from  home  to  water-cure  establishments  in  which  water  is  any- 
thing but  scientifically  applied. 

THE  COLD  RUB. 

This  is  the  "  kalte  Abreibung  "  of  the  Germans,  who  apply  it  usually 
in  the  morning  on  rising  from  bed,  while  the  patient  is  still  warm.  It 
is  a  modification  of  the  drip  sheet. 

Technique. — A  linen  sheet,  preferably  of  coarse  texture,  is  wrung 
out  of  water  at  60°-75°  and  quickly  wrapped  around  the  patient  in  the 
manner  described  above.  Frictions  are  made  by  rapid  passes,  as  with 
the  drip  sheet,  but  there  is  more  active  rubbing  done,  because  the 
object  here  is  not  to  abstract  heat  but  to  produce  a  decided  cutaneous 
hyperaemia.  Frequent  slapping  (Abklatschen)  facilitates  the  attain- 
ment of  this  object. 


124       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTH£RAPY. 

The  duration  of  this  procedure  varies  with  the  object  in  view. 
After  the  rub  the  sheet  is  dropped;  the  patient  is  rapidly  dried, 
dressed,  and  preferably  sent  into  the  open  air  after  partaking  of  a  cup 
of  hot  milk.  The  therapeutic  indications  of  this  procedure  are  anaemia 
of  feeble  persons,  phthisis,  and  other  conditions  of  defective  haematosis. 

Some  neurologists  have  recommended  this  method  under  the  name  of 
"  drip  sheet"  as  an  excellent  procedure  in  rest-cure  cases,  for  promoting 
sleep.  The  indefiniteness  of  current  hydriatric  terminology  is  illus- 
trated by  terming  this  procedure  a  drip  sheet.  The  sheet  can 
not  "drip"  after  it  is  wrung  out.  This  erroneous  term  seems 
to  have  been  perpetuated,  as  in  several  recent  works  a  "  drip  sheet" 
is  briefly  described  as  being  prepared  by  "  wringing  a  sheet  out  of  cold 
water,"  etc.  Such  errors  must  be  avoided  in  discussing  procedures; 
the  latter  should  be  definitely  described  or  stated. 

In  nephritis,  especially  in  the  contracted  kidney,  von  Noorden 
praises  the  cold  rub  very  highly,  in  a  discussion  before  the  Balneologi- 
cal Society.*  He  opposes  the  prejudice  against  cold  water,  which  has 
long  prevailed,  but  is  unfounded.  Von  Noorden  insists  that  even  in 
chronic  kidney  diseases  the  judicious  use  of  cold  rubs  may  be  of  great 
benefit :  "  I  scarcely  know  another  procedure  which  is  more  lasting  and 
more  useful  than  the  'kalte  Abreibung,'  followed  by  strong  friction^ 
which  renders  the  skin  red  and  dry  in  reaction.  I  desire  to  emphasize 
that  cold  water  need  not  always  be  avoided." 

In  the  same  discussion  Winternitz  insists  with  his  usual  energy 
upon  the  fact  that  when  reaction  is  produced  by  the  cold  application 
there  need  never  be  any  fear  of  low  temperatures.  Such  reaction  can- 
not, as  he  justly  claims,  be  evoked  by  lukewarm  water. 

Groedel  (Nauheim),  while  opposed  to  cold  water  in  nephritis  gen- 
erally, favors  any  cold  procedure  which  really  produces  a  good  reaction. 

See  "Therapeutics  of  Wet  Pack." 

THE  WET  PACK. 

The  wet  pack  has  been  applied  for  a  very  long  time  in  the  practice 
of  hydrotherapy.  This  procedure  is  not,  as  has  been  claimed,  an  in- 
vention of  Priessnitz.  It  was  described  by  Lucas,  an  English  phy- 
sician, in  1750.  Doubtless  Priessnitz  discovered  it  independently,  for 
he  was  too  unlettered  to  have  been  aware  of  Lucas'  writings.  The 
followers  of  the  peasant  water  doctor  apply  the  wet  pack  more  fre- 
quently than  any  other  procedure.  The  wet  pack,  like  all  other  hydri- 
atric measures,  requires  care  and  precision  in  its  application  in  order  to 
*  Deutsche  Medizinal-Zeitung,  1900,  No.  49. 


THE   PRACTICE   O?   HYDEOTHEEAPY. 


125 


be  followed  by  good  results.  A  dread  of  damp  sheets  is  in  the  minds 
of  the  lay  people  so  intimately  associated  with  rheumatism  and  colds 
that  the  idea  of  being  placed  into  a  wet  pack  calls  forth  a  shudder  in 
the  patient  to  whom  it  is  novel,  while,  on  the  other  hand,  the  hydro- 
paths  who  are  familiar  with  it  have  brought  it  into  disfavor  by  claim- 
ing innocuity  and  all  manner  of  curative  virtue  for  it. 

The  technique  of  the  wet  pack  is  as  follows:  Two  large  woollen 
blankets  are  spread  upon  a  hair  ov  other  mattress,  most  appropriately 
placed  (if  a  wire  mattress  is  used  a  rubber  sheet  must  intervene  to 
protect  it  from  the  moisture)  upon  a  high  four-legged  cot,  best  located 
in  the  middle  of  the  room,  so  that  the  attendant  may  have  ready  access 
to  it  from  all  directions.  A  large  coarse  linen  sheet,  well  wrung  out  of 
water  of  a  temperature  of  from  60°  to  70°,  appropriate  to  the  case,  is 


FIQ.  26.  —Wet  Pack  in  Readiness,  Showing  Wet  Sheet  and  Blanket. 

spread  upon  the  blanket,  which  should  be  long  enough  to  extend  two 
feet  or  more  beyond  the  patient' s  extremities,  and  so  placed  that  its 
left  third  hangs  over  the  left  edge  of  the  cot  (Fig.  26) .  The  patient, 
provided  with  a  wet  turban,  now  lies  upon  the  cot  with  arms  elevated 
above  his  head,  so  that  he  occupies  the  junction  of  the  middle  with 
the  right  third  of  the  sheet.  The  latter  is  now  drawn  across  the  body 
from  right  to  left ;  its  upper  portion  is  tucked  along  the  left  side  of 


126        THE   PRINCIPLES   AND    PRACTICE   OF    IIYDROTHE11APY. 

the  trunk;  its  lower  portion  is  placed  between  the  lower  extremities 
(Fig.  27).  The  arms  are  now  restored  to  the  side  of  the  body;  the 
left  overhanging  portion  of  the  sheet  is  brought  over  from  left  to 
right  so  as  to  envelop  the  arms  and  entire  body,  and  its  border  is 
tucked  along  the  right  side,  and  its  lower  end  is  tucked  under  the  heels, 


FIG.  27.— Wet  Pack.     Sheet  drawn  from  right  to  left. 

thus  enclosing  the  feet.  In  feeble  persons  the  feet  may  be  left  un- 
covered by  folding  the  wet  sheet  back  toward  the  knees,  as  shown  in 
Fig.  28.  The  blanket  is  now  drawn  firmly  from  the  left  and  tucked 
under  the  right  side  of  the  body,  the  right  border  of  the  blanket  being 
drawn  over  to  the  left  in  the  same  manner,  firmly  secured  under  the 
body,  and  its  upper  corner  drawn  around  the  neck  and  secured  beneath 
it  (Fig.  29).  In  executing  this  procedure  the  edge  of  the  blanket 
should  be  grasped  by  the  left  hand  about  eighteen  inches  from  the 
shoulder  and  drawn  firmly  over  the  latter  and  held  at  a  right  angle  to 
it,  close  to  the  body,  while  the  right  hand,  grasping  the  edge  of  the 
blanket  lower  down,  carries  it  across  over  the  other  shoulder  and  tucks 
it  beneath  the  latter.  The  left  hand  performs  here  the  same  function 
as  it  does  in  the  reversing  of  a  bandage.  The  lower  border  is  firmly 
tucked  around  and  over  the  feet.  Everything  depends  upon  complete 
exclusion  of  air  from  beneath  the  blanket  cover.  The  patient  is  now 


THE   PRACTICE   OF   HYDRO-THERAPY. 


127 


covered,  with  several  woollen  blankets,  if  he  is  chilly.  If  the  covering 
has  been  skilfully  clone,  the  patient  will  resemble  a  mummy  whose 
head  is  enveloped  in  a  wet  turban  (Fig.  30). 

Modifications  of  this  procedure  consist  in  partial  packs,  in  which 
only  parts  of  the  body  below  the  axilla  are  enveloped  in  the  damp 
sheet.  The  duration  of  the  pack  (which  should  be  from  one-half  hour 
to  an  hour),  the  texture  of  the  sheet,  the  temperature  of  the  water,  and 
the  extent  of  the  pack,  as  well  as  its  repetitions,  modify  the  effect  ma- 
terially, as  will  be  seen.  All  wet  packs  must  be  followed  by  some  hy- 
driatric  method  which  restores  tone  to  the  cutaneous  vessels  that  have 
been  relaxed  by  it.  Either  a  half- bath  or  a  cold  affusion  will  serve  the 


FIG.  28.— Wet  Pack,  Second  Stage.     Sheet  carried  from  left  to  right. 

end,  and  these  are  selected  with  regard  to  the  need  of  each  separate 
case.  In  institutions,  the  circular  bath  and  douche  of  70°  to  80°  afford 
a  more  pleasant  because  more  rapid  sequel  to  the  wet  pack.  The  room 
in  which  the  wet  pack  is  administered  should  be  well  ventilated  until 
a  short  time  before  the  patient  is  removed. 

Rationale  of  the  Wet  Pack. — The  first  effect  of  contact  with  the 
cold  damp  sheet  is  an  irritation  of  the  cutaneous  nerves  and  vessels, 
which  induces  contraction  of  the  peripheral  vessels,  and  which  continues 
until  the  individual's  power  of  reaction  comes  into  play.  This  de- 


128        THE   PRINCIPLES   AND   PRACTICE   OF    IIYDROTHERAPY. 

pends,  as  in  all  hydriatric  procedures,  upon  the  age  and  condition  of 
the  patient;  old  people  and  children  do  not  react  so  readily  as  adults, 
and  a  previous  high  temperature  of  the  skin  furthers  rapid  reaction,  as 
does  also  a  vigorous  normal  condition.  It  should  be  borne  in  mind 
that  the  wet  pack  differs  from  the  preceding  methods  in  an  important 
respect.  There  being  no  mechanical  aid  given  by  attendants,  as  in  the 
sheet  bath  or  half -bath,  reaction  depends  entirely  upon  the  vital  powers 
of  the  patient.  This  fact  distinguishes  the  wet  pack  completely  from 
all  other  hydriatric  procedures,  and  demands  judicious  recognition  of 


FIG.  29.  —Mode  of  Securing  Blanket,  rubber  sheet  being  shown  hanging  over  cot. 

the  patient's  reactive  capacity.  For  this  reason  it  should  not  be  re- 
sorted to  until  the  latter  has  been  ascertained  or  trained  by  other 
procedures. 

As  soon  as  the  first "  shock  "  is  over,  which  lasts  from  five  to  ten 
minutes,  and  sometimes  produces  shivering,  the  cutaneous  vessels 
begin  to  dilate;  warm  blood  flows  from  the  centre  to  the  periphery,  in 
the  effort  the  system  makes  to  equalize  the  temperature  between  the 
skin  and  the  sheet.  When  the  body  temperature  is  high,  as  in  fevers, 
there  is  no  chilliness.  The  cooled  blood  is  at  first  driven  from  the 
surface  to  the  subjacent  structures,  but  very  soon  the  warm  blood  from 


THE   PRACTICE   OF   HYDROTHERAPY. 


129 


the  interior  takes  its  place,  and  dilatation  of  the  cutaneous  vessels  is 
the  result.  This  continuous  interchange  of  temperature,  which  occurs 
easily  and  slowly  in  patients  with  normal  temperature,  gives  rise  to  a 
vaporization  from  the  sheet  which,  in  fever,  furthers  loss  of  heat  from 
the  skin.  The  latter  is  increased  by  radiation  from  the  blanket,  and  by 
the  state  of  rest  in  which  the  patient  is  placed  and  the  consequent  forma- 
tion of  a  vapor  which  envelops  the  entire  body.  This  continues  as  long 
as  the  sheet  remains  cool  and  just  as  long  as  the  thermic  irritation  is 
renewed,  more  feebly  each  time,  until  the  sheet  is  thoroughly  warmed. 


FIG.  30.  —Wet  Pack,  Complete. 

After  the  sheet  and  skin  have  reached  the  same  temperature,  a  con- 
dition which  requires  about  ten  minutes  under  fairly  good  circulation, 
the  patient  lies  in  a  damp  sheet  of  neutral  temperature.  The  oxida- 
tion processes  Avhich  are  aroused  by  the  primary  action  of  the  cold 
sheet,  to  protect  the  organism  against  the  baneful  effect  of  disturbance 
of  the  heat  equilibrium,  do  not  cease,  however,  after  they  have  been  set 
in  motion.  The  normal  production  of  heat  continues,  but  the  normal 
loss  of  heat  by  radiation  and  vaporization  is  inhibited  and  conduction 
is  greatly  diminished  by  the  woollen  blankets  enveloping  the  patient. 
The  result  is  an  accumulation  of  heat  on  the  surface  of  the  body. 
9 


130        THE    PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

This  contributes  to  the  vaporization  of  the  moisture  in  the  sheet.  The 
patient  now  lies  in  a  warmer  medium  than  that  of  the  ordinary  cloth- 
ing. Consequently  he  is  soothed  as  in  a  warm  bath.  If  the  pack  is 
continued  over  an  hour,  the  accumulated  heat  manifests  itself  by  perspi- 
ration on  the  forehead.  The  patient  now  is  in  a  superheated  medium, 
and  obtains  all  the  physiological  effects  described  above.  If  a  pack 
is  prolonged  several  hours,  Ziegelroth*  has  found  the  additional 
effect  of  elimination  of  toxins.  After  detailing  how  the  primary  irri- 
tation by  cold  arouses  a  reflex  excitation  of  the  respiratory  and  car- 
diac centres,  and  how  reaction  ensues,  producing  a  widening  of  the 
cutaneous  vascular  area,  the  skin  is  so  filled  with  blood  and  heated 
by  the  latter  that  after  an  hour  the  sheet  will  steam  on  removal. 
This  hypersernization  of  the  skin  should  not  be  interrupted,  but- 
the  wet  pack  may  continue  several  hours.  The  skin  now  excretes 
more  actively,  producing  evaporization  into  and  through  the  damp 
sheet.  The  odor  of  the  latter  when  removed  often  bears  testimony 
to  this  enhanced  excretion.  The  relief  felt  by  most  patients  Ziegelroth 
ascribes,  aside  from  the  favorable  influence  upon  the  circulation,  to  the 
removal  of  toxins.  Although  this  latter  claim  has  not  been  sufficiently 
well  demonstrated,  the  odor  of  the  sheet  is  substantiative  evidence. 
It  has  been  specially  observed  in  acute  rheumatism.  This  eliminative 
process  is  aided  materially  by  the  excitation  of  cellular  combustion, 
induced  by  the  pack.  No  better  measure  is  open  to  the  physician  for 
furthering  intra-organic  oxidation,  for  the  combustion  of  autotoxins,  for 
transmutation  of  the  products  of  regressive  metamorphosis  into  soluble 
substances  capable  of  elimination.  Bouchard,  who  is  a  well-known 
authority  on  the  subject,  has  said :  "  Chose  remarquable,  ces  homines 
a  secretions  sudorales  fetides  cessent  d'exhaler  une  odeur  mauvaise, 
s'ils  viennent  d'etre  atteints  de  quelque  maladie  febrile."  It  is  positive 
that  these  autotoxins  are  consumed  in  the  powerfully  enhanced  combus- 
tion which  represents  the  fever  process,  and  that  they  are  thus  elimi- 
nated from  the  organism.  The  so-called  "curative  power  of  fever" 
probably  is  due  to  this  oxidation  of  toxins  and  autotoxins,  and  it  may 
also  be  the  reason  why  sometimes  chronic  diseases  are  removed  by 
acute  intercurrent  diseases,  and  why  many  individuals  feel  much  better 
after  acute  febrile  diseases.  The  prolonged  applications  of  the  wet 
pack,  two  to  three  hours,  would  therefore  seem  to  offer  upon  this 
rationale  a  method  of  elimination  which  may  serve  many  useful  thera- 
peutic purposes. 

Experiments  upon  animals  for  the  demonstration  of  the  rationale 
of  the  wet  pack  are  not  wanting. 

Schuller  has  shown   the  action   of   the  wet  pack  upon  trephined 

*  Deutsche  Medizinal-Zeituner.  July  5th,  1897. 


THE   PRACTICE   OF   HYDROTHERAPY.  131 

rabbits.  He  wrapped  them  in  a  sheet  wet  with  water  at  34°,  and 
covered  them  with  wax  cloth  and  woollen  blankets,  snugly  tied  up, 
so  as  to  leave  only  the  head  free,  and  laid  them  for  two  or  three  hours 
upon  a  table.  The  temperature  sank  one  or  two  degrees,  but  began 
to  rise  again  in  two  and  a  quarter  hours.  The  respiration  became  more 
slow  and  deep,  and  the  pulse  less  frequent.  The  animals  reacted  less 
to  irritants  and  at  first  seemed  to  be  drowsy,  but  with  the  rise  of  tem- 
perature they  became  more  lively  and  began  to  kick  actively.  A. 
striking  effect  upon  the  vessels  of  the  pia  mater,  which  had  been  ex- 
posed by  trephining,  was  noted.  After  a  primary  rapid  dilatation  the 
vessels  became  narrower,  the  brain  sank  in  more  and  more,  and  the 
dura  mater  was  raised  up  by  cerebro-spinal  fluid,  which  accumulated 
abundantly  underneath  it.  The  cerebral  movements  became  more  slow 
and  more  equable.  This  lasted  several  hours.  External  irritants, 
pinching,  rubbing,  or  lifting  the  animals,  produced  at  first  rapid  but 
afterward  shorter  cerebral  movements  and  greater  but  changing  dila- 
tation of  the  vessels.  As  soon  as  the  pack  was  removed  dilatation 
of  the  vessels  occurred,  but  they  soon  resumed  their  normal  calibre. 
Respiration  and  cerebral  movement  became  more  frequent.  Warm 
compresses  upon  the  belly  and  back  of  the  animal  produced  a  contrac- 
tion of  the  vessels  of  the  pia,  with  acceleration  of  pulse  and  respira- 
tory movements ;  the  former  became  less  perceptible,  the  latter  more 
shallow. 

These  experiments  render  the  action  of  the  wet  pack  upon  the 
human  body  intelligible.  We  often  find  the  patient  slumbering  as 
soon  as  the  temperature  is  equalized  between  the  body  and  the  sheet, 
and  warmth  is  evolved  by  the  reactive  process,  which  fills  the  cutane- 
ous vessels  and  thus  diminishes  the  amount  of  blood  in  the  cerebral 
vascular  area.  Moreover,  the  quiescent  state  of  the  patient,  and  the 
removal  of  all  those  reflex  influences  which  arise  from  the  cutaneous 
nerves  and  are  conveyed  to  the  brain  in  ordinary  conditions,  must  con- 
tribute to  the  calming  effect  of  the  wet  pack. 

The  effect  of  the  wet  pack  upon  the  muscular  system  has  received 
careful  attention  from  Vinaj  and  Maggiora.  *  After  retaining  the  indi- 
vidual in  the  wet  pack  two  hours,  the  left  middle  finger  was  exposed 
and  its  fatigue  curve  taken  (Fig.  31).  Immediately  afterward  he  was 
removed  from  the  pack  and  dipped  into  a  tub  of  cold  water.  Now  the 
"  fatigue  curve"  of  the  right  middle  finger  was  taken  (Fig.  32).  These 
were  compared  with  the  normal  curve  taken  before  the  pack,  which 
was  identical  with  Figs.  1  and  2. 

*  Blatter  fur  klinische  Hydrotherapie,  1892. 


1.32        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

TABLE  SHOWING  MUSCULAR  LIFTING -CAPACITY  AFTER  WET  PACK. 


Curves. 

Conditions  of  Experiment. 

LEFT  HAND. 

RIGHT  HAND. 

Lifted, 
Height. 
Metres. 

Working 
Result. 
Kgm. 

Lifted, 
Height. 
Metres. 

Working- 
Result. 
Kgm. 

(1)   Fig.  31  

After  wet  pack  .         .... 

2.370 

7.110 

3.840 
1.690 

11.520 
5.070 

(2)   Fig.  32  

After  cold  dip  

3                

Normal 

1.737 

5.211 

Normal  

This  table  shows  the  enormous  increase  of  lifting-capacity  after  the 
wet  pack  followed  by  the  usual  cold  bath,  and  it  furnishes  a  partial 
rationale  for  the  tonic  effect  usually  derived  from  this  procedure.  It 
appears  to  the  author  that  this  "  tonic  effect "  is  not  due  to  the  wet 


FIG.  31  .—Fatigue  Curve  of  Left  Hand, 
after  wet  pack  of  two  hours. 


FIG.  32.— Fatigue  Curve  of  Right  Hand,  after  pack 
find  cold  dip. 


pack  of  two  hours,  but  to  the  cold  dip  following  it,  when  the  skin  has 
been  superheated  in  the  prolonged  wet  pack. 

Therapeutic  Indications  of  the  Wet  Pack. — If  abstraction  of  heat 
is  the  chief  aim,  the  temperature  of  the  sheet  should  be  60°  to  70°  for 
the  first  pack ;  the  patient  must  be  removed  from  the  pack  when  the 
latter  is  warm,  and  placed  in  another  two  degrees  higher,  which  has 
been  prepared  on  the  same  or  on  an  adjoining  bed.  He  is  again  removed 
into  another  pack  of  two  degrees  higher  as  soon  as  he  warms  the  sheet 
and  superincumbent  blanket,  which  is  ascertained  by  applying  the  hand 
to  various  parts.  Liebermeister  has  shown  that  five  such  wet  packs  of 
ten  minutes'  duration  will  abstract  as  much  heat  as  one  full  bath  at 
65°  F.  for  fifteen  minutes.  When  the  temperature,  therefore,  is  high 
(above  102°),  or  when  insurmountable  objection  is  made  to  other  more 
or  less  heroic  measures,  the  wet  pack  is  a  useful  and  acceptable  alterna- 


THE   PRACTICE   OF   HYDKOTHEKAPY.  133 

tive  in  fevers.  The  physician  must  decide  whether  he  would  prefer  rlve( 
packs,  consuming  fifty  minutes'  time,  to  a  full  bath  of  fifteen  minutes. 
The  character  of  the  case  will  aid  him  in  this  decision.  My  own  ex- 
perience is  in  favor  of  the  full  bath,  if  the  ablution  and  sheet  bath  and 
half-bath  have  proved  insufficient,  and  the  proper  help  and  tubs  can  be 
obtained.  For  mild  cases,  however,  with  temperature  of  100°  to  103°, 
especially  in  cases  of  non-infectious  type,  this  pack  is  an  admirable  anti- 
febrile remedy.  As  it  may  be  modified  by  repetition  of  sheets  wrung 
out  of  water  of  higher  temperature,  each  application  being  of  longer 
duration,  if  the  body  continues  to  cool,  or  by  lowering  the  temperature 
of  the  damp  sheet  if  the  body  temperature  does  not  fall,  we  possess  in 
the  pack  a  most  flexible  remedy — subject  to  accurate  dosage,  as  it  were. 
Tn  fevers,  the  first  impression  of  cold  upon  the  surface  will  cease 
abruptly  and  give  way  to  the  first-mentioned  process  of  vaporization. 
This  induces  a  soothing  effect  upon  the  peripheral  vessels  and  nerves, 
and  in  patients  who  have  been  tossing  restlessly  sleep  often  ensues. 

If  this  calming  effect  be  the  chief  indication  at  that  period  of  the 
disease,  the  patient  having  lost  sleep  or  being  on  the  verge  of  delirium, 
it  would  be  wise  to  permit  him  to  remain  in  the  pack  until  he  awakens, 
and  then  give  him  a  rapid  cold  ablution.  If,  however,  the  high  tem- 
perature without  depreciated  nerve  tone — adynamia — be  the  therapeutic 
indication,  the  patient  should  be  removed  from  the  pack  as  soon  as  the 
blanket  or  sheet  beneath  begins  to  feel  warm.  He  should  now  be 
put  into  another  pack,  as  directed  above,  the  process  being  repeated 
until  four  or  five  packs  have  been  given,  or  the  temperature  has  been 
sufficiently  reduced,  precaution  always  being  observed  to  permit  him 
to  remain  in  the  last  pack,  which  cools  but  does  not  chill  him,  for  ten 
or  fifteen  minutes.  If  he  is  not  too  much  fatigued,  a  rapid  ablution 
with  water  of  from  50°  to  60°  should  be  administered  before  he  is 
again  dressed.  This  method  is  slower,  but  its  effect  is  more  enduring 
than  the  more  rapid  cooling  by  the  full  bath,  for  the  reason  that  the 
compensating  elevation,  which  is  the  normal  conservative  reaction,  is 
more  deliberate  and  tardy. 

When  in  typhoid  or  other  adynarnic  conditions  other  cold  procedures 
produce  chilling,  the  author  has  obtained  marked  results  from  a  modi- 
fication in  the  technique  of  the  wet  pack  which  has  thus  proved  valu- 
able in  many  emergencies. 

Guided  by  the  idea  that  the  chilling  effect  of  ablutions  or  baths  is 
due  to  lack  of  responsive  action  in  the  cutaneous  vessels,  I  have  had 
the  wet  pack  prepared  on  an  adjoining  cot  or  bed  by  laying  two  thick 
and  large  woollen  blankets,  over  these  a  thin  blanket,  and  on  the  lat- 
ter a  coarse  linen  sheet  well  wrung  out  of  water  at  70°-60° — the  colder 
water  being  the  more  useful.  Care  should  be  taken  that  the  patient 


134       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

be  rapidly  enveloped  in  the  damp  sheet  and  successively  in  each 
blanket.  So  soon  as  he  declares  himself  quite  comfortable  or  warm, 
the  outer  thick  blanket  is  removed,  and  in  five  or  ten  minutes  the  sec- 
ond blanket  is  also  removed,  and  the  patient  is  IIOAV  permitted  to 
remain  in  the  thin  blanket  for  five  to  ten  minutes.  He  should  not  be 
removed  at  all  if  he  falls  asleep,  as  is  frequently  the  case.  By  this 
measure  the  lack  of  reactive  capacity  and  fears  of  the  patient  may  be 
circumvented  and  all  the  antifebrile  effects  of  cold  water  obtained — 
stimulation  by  the  first  cold  impact,  reaction  after  being  wrapped, 
cooling  by  capillary  evaporation  through  the  thin  blanket,  and  if 
necessary  another  stimulation  by  rapid  rubbing  with  a  cold  damp  towel 
or  an  alcohol  rub  or  a  cold  ablution.  A  few  packs  of  this  type  may 
prepare  the  patient  for  ablutions,  sheet  baths,  or  tub  baths,  which  he 
will  now  bear  without  ill  effect. 

Many  corroborative  contributions  from  practical  hospital  physicians 
may  be  cited  in  favor  of  the  wet  pack  in  acute  diseases.  Rendu  *  offers 
the  results  of  ten  years'  observations  Avith  the  wet  pack.  He  claims 
that  it  may  be  readily  substituted  for  the  cold  full  bath;  that  it  reduces 
temperature  and  favors  elimination  of  toxic  products ;  that  it  relieves 
the  kidneys,  refreshes  the  nerves  and  prevents  cardiac  collapse ;  that  the 
lay  public  would  more  readily  accept  the  cold  wet  pack  than  the  cold 
bath ;  that  it  is,  therefore,  more  applicable  in  private  practice.  Kendu 
yields  to  the  prejudices  of  people  who  insist  upon  medication,  by  adding 
some  innocent  vegetable  decoction  or  salt  to  the  water  of  the  pack.  He 
claims  that  neither  age  nor  constitution  offers  a  contraindication  to 
the  wet  pack.  He  lauds  the  prolonged  wet  pack  especially  in  acute 
nephritis  (in  which  Kussmaul  has  recommended  it),  and  he  opposes  all 
diuretic  remedies.  See  page  137  for  wet  pack  in  nephritis. 

Wachsmuth  has  recommended  the  wet  pack  in  severe  diphtheria, 
losing  three  cases  out  of  fifty,  two  of  which  were  in  extremis. 

Rationale  in  Chronic  Disease. — If  the  body  temperature  is  normal 
or  a  little  above  normal,  as  is  the  case  in  most  chronic  diseases,  the 
thermic  irritation  is  the  same  as  in  acute  disease,  but  the  response  to 
it  is  quite  different,  owing  to  the  usually  depreciated  nerve  tone  and 
diminished  reactive  capacity.  The  peripheral  vessels  are  contracted; 
the  patient  probably  shivers  longer,  because  the  surface  is  not  so 
rapidly  supplied  with  fresh  blood  and  the  latter  is  more  readily  cooled. 
In  extreme  youth  and  in  old  age  the  power  of  reaction  to  the  thermic 
irritation  is  diminished.  This  also  depends  upon  the  more  or  less  vigor- 
ous condition  of  the  patient,  and,  to  a  certain  extent,  upon  his  tem- 
perature. The  cooling  effect  lasts  ten  minutes  or  longer,  during  which 
time  the  patient  feels  somewhat  uncomfortable,  and  often  begs  to  be 
*  Revue  d' Hygiene  Therapeutique,  June,  1893. 


THE   PRACTICE   OF   HYDROTHEEAPY.  135 

removed  from  the  pack.  The  first  impact  of  cold  upon  the  surface, 
too,  often  produces  gasping  respiration  and  enhances  the  discomforts 
experienced.  These,  however,  pass  away  more  or  less  quickly.  The 
equalization  between  the  body  temperature  and  that  of  the  damp  sheet 
and  the  evaporation  from  the  latter  envelop  the  body,  in  a  vapor  of 
its  own  creation.  The  relative  labor  to  which  the  system  is  thus  sub- 
jected is  of  great  benefit  to  the  circulation,  and  it  has  been  demon- 
strated that  it  aids  in  enhancing  tissue  metamorphosis.  The  patient, 
lying  quietly  in  the  pack,  often  falls  asleep.  Indeed,  I  have  seen  at 
Professor  Winternitz's  institution  at  Kaltenleutgeben  numbers  of  pa- 
tients soundly  sleeping,  although  the  packs  were  usually  given  before 
7  A.M.,  i.e.,  just  after  rising  from  bed. 

The  calmative  effect  of  an  hour's  sleep  in  a  gentle  poultice,  as  it 
were,  is  valuable  in  functional  neuroses,  hysteria,  and  some  heart 
troubles,  as  will  be  shown. 

Max  Herz,  of  Vienna,  *  calls  attention  to  the  fact  that  by  the  wet 
sheet  the  epidermis  is  saturated  with  water.  He  investigated  the  radia- 
tion of  heat  in  a  feverish  tuberculous  patient,  and  discovered  that  de- 
spite an  elevated  axillary  temperature,  the  patient  did  not  lose  more 
heat  by  radiation  than  did  one  who  was  free  from  fever  in  the  same 
environment.  Herz  then  soaked  the  skin  thoroughly  and  found  that 
heat  radiation  increased.  Radiation  depends  upon  the  condition  of  the 
cutaneous  surface,  and  there  can  be  no  doubt  that  a  succulent  epidermis 
radiates  heat  more  readily  than  a  dry  skin.  The  heat  given  off  by  the 
epidermis  is  always  replaced  by  heat  furnished  by  the  blood  circulating 
beneath  it.  If  the  epidermis  is  a  bad  conductor,  loss  of  blood  heat 
meets  greater  resistance,  while  in  a  better  conducting  condition  it 
literally  "sucks  up"  the  heat.  These  observations  afford  a  rational 
explanation  of  the  antithermic  effect  of  wet  packs. 

In  an  able  monograph  on  the  wet  pack  and  massage,  the  late  Dr. 
Mary  Putnam  Jacobi  furnishes  so  intelligent  and  comprehensive  an 
explanation  of  the  wet  pack  that  I  reproduce  it  in  testimony  of  my  ap- 
preciation of  this  contribution  to  the  subject  by  an  American  physician. 

"  The  increased  production  of  heat,  determined  by  the  stimulation 
of  the  heat-regulating  apparatus,  irrespective  of  the  amount  of  heat 
abstracted  by  the  cold,  involves  functional  activity  (1)  in  the  sensi- 
tive afferent  nerves ;  (2)  in  one  or  more  parts  of  the  nerve  centres ;  (3) 
in  centrifugal  nerve  fibres  of  some  kind  terminating  in  muscles;  (4) 
in  the  muscles  where  are  performed  the  chemical  processes  involved  in 
the  production  of  heat.  Thus  the  organism  is  induced  to  perform  a 
definite  and  not  inconsiderable  amount  of  work.  On  this  account  its 
nervo-muscular  tissues,  or  a  large  portion  of  them,  are  brought  into  a 

*Monatschrift  ftir  praktische  Heilkunde,  Juli,  1895. 


136       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

condition  favorable  to  nutritive  assimilation.  But  this  is  not  all. 
When  the  reaction  after  the  cold  pack  is  normal,  the  column  of  blood 
which  sets  inward  toward  the  chylopoetic  viscera  very  soon  turns  out- 
ward again,  accelerating  the  entire  circulation  of  these  organs  in  the 
same  direction.  As  a  most  important  result,  more  nutriment  is  car- 
ried into  the  general  circulation,  and  with  the  abatement  of  the  gastro- 
intestinal hyperaemia  the  appetite  revives. 

"Sleepiness  during  the  pack  nearly  always  occurs  in  successful 
cases,  and  we  have  found  the  greatest  benefit  to  accrue  when  the  pa- 
tient was  able  to  sleep  for  half  an  hour  after  the  completion  of  the  pack 
and  massage.  If  we  may  assume,  for  reasons  already  stated,  that 
during  the  first  period  of  the  pack  blood  circulates  in  increased  volume 
and  under  increased  pressure  through  the  nerve  centres,  and  that  in 
consequence  the  acid  fatigue  products,  which  have  been  maintaining  a 
permanent  excitation  of  nerve  elements,  can  be  completely  removed, 
the  immediately  subsequent  diminution  of  blood  supply,  effected  dur- 
ing the  second  part  of  the  pack,  cannot  fail  to  be  a  great  advantage, 
for  it  lowers  the  functional  activity  of  the  nerve  tissues  that  has  been 
unduly  prolonged,  and  brings  them,  therefore,  into  the  condition  which 
is  a  necessary  preliminary  to  the  beginning  of  nutritive  assimilation. 
The  diminution  of  blood  supply  is  not  sufficient  to  interfere  with  this 
latter  process,  for  it  is  not  below  the  point  which  exists  in  sleep,  the 
physiological  period  of  the  nutritive  assimilation  in  nervo-muscular 
tissues.  Accepting  Ranke's  law  for  these  tissues,  that  they  are  only 
nourished  when  fatigued,  i.e.,  relaxed,  we  may  see  further  in  the  mus- 
cular relaxation  induced  by  the  warm  moisture  of  the  pack  a  condition 
most  favorable  for  the  nutrition  of  the  muscles." 

Modifications  of  the  Wet  Pack. — The  modifications  to  which  the 
action  of  the  wet  pack  may  be  subjected  by  slight  changes  in  its  tech- 
nique explain  why  the  hydropaths  have  lauded  this  procedure  since 
the  days  of  Priessnitz  as  a  panacea  for  all  ills.  The  practical  observa- 
tions of  these  empirics  are  worthy  of  regard.  Even  their  singular 
claim  of  withdrawing  poisons  from  the  blood  by  this  measure  is  not 
entirely  without  scientific  foundation.  While  we  may  accept  their 
statements  and  claims  cum  grano  sails,  it  is  wise  to  test  them 
clinically.  This  has  been  done  by  VVinteruitz,  Kussmaul,  and  the 
author. 

The  modification  of  the  wet  pack  for  cooling  purposes  has  been 
referred  to  in  the  description  of  its  applications  in  fevers.  Similar 
modifications  of  effect  may  be  obtained  by  modifying  the  duration  of 
the  procedure.  In  patients  coming  under  treatment  with  a  nearly 
normal  temperature,  the  reactive  capacity  may  be  first  increased  by 
friction,  the  dry  pack,  or  a  hot-air  bath.  This,  however,  is  rarely  nee- 


THE   PRACTICE   OF   HYDROTHERAPY.  137 

essaiy,  when  the  sheet  is  coarse  and  well  wrung  out  of  water  not  above 
70°  and  the  patient  is  rapidly  enveloped  in  it  and  covered  as  directed 
(Fig.  118)  by  the  blankets.  The  chilling  effect  of  the  cold  sheet  is 
soon  neutralized  by  heat  furnished  by  the  organism,  which  has  been 
aroused  to  defend  the  attack  upon  the  skin.  So  soon  as  the  tempera- 
ture of  the  sheet  reaches  that  of  the  normal  skin  (about  90°),  chilling 
diminishes.  If  the  pack  is  continued,  the  supply  of  heat  from  the 
interior  increases  the  temperature  of  the  skin  and  sheet,  because  the 
heat  production  continues  after  it  is  once  aroused  for  the  compensa- 
tion of  the  initial  heat  abstraction. 

The  warm  moisture  now  enveloping  the  patient  produces  a  calm- 
ing effect,  which  may  be  continued  by  removing  the  outer  blanket  to 
counteract  the  increase  of  heat  which  continues  to  form  as  a  result  of 
the  primary  stimulus  of  cold. 

If  the  blanket  covering  be  increased,  on  the  contrary,  or  a  rubber 
sheet  be"  placed  over  the  pack,  heat  diffusion  will  be  checked  more 
or  less,  the  skin  will  become  hypersemic,  the  face  flushed,  and  all 
the  phenomena  of  a  hot  bath  will  ensue,  even  to  abundant  perspiration 
of  the  face.  The  amount  of  actual  functional  work  of  the  entire  or- 
ganism which  this  process  demands  may  be  utilized  for  the  benefit 
of  the  patient,  or  become  detrimental  if  injudiciously  evoked  and 
applied. 

In  Nephritis. — When  the  excellent  investigations  of  Kaufmannand 
Barrie  (Berliner  klin.  Wochenschrift,  1888,  No.  28)  on  the  cold  wet 
pack  in  nephritis,  etc.,  made  in  Kussmaul's  Clinic,  came  to  the  author's 
attention,  he  recognized  that  the  results  must  be  due  to  the  above  briefly 
stated  rationale,  and  he  has  adopted  the  cold  wet  pack  as  superior  to 
other  heating  procedures  in  many  cases  of  nephritis,  gout,  and  rheu- 
matism. When  the  body  temperature  is  above  the  normal  or  when  the 
attack  is  sudden,  as  in  the  albuminuria  and  even  in  eclampsia  of  preg- 
nancy, reaction  ensues  very  rapidly  if  the  wet  pack  is  judiciously  given. 
Diaphoretic  action  ensues,  and  all  the  favorable  results  that  may  arise 
from  diaphoresis  are  enhanced  by  the  improved  condition  of  the  circu- 
lation, general  and  local,  which  have  been  demonstrated  as  resulting 
from  the  wet  pack. 

Hot  Blanket  Pack. — This  measure  is  so  frequently  referred  to  in 
the  literature  of  nephritis  that  its  technique  may  be  appropriately 
described.  The  usual  method  is  as  follows :  Three  or  four  woollen 
blankets  are  placed  upon  a  bed  or  cot;  the  upper  one  is  wrung  out  of 
water  as  hot  as  the  attendants  can  bear  it  on  their  hands,  by  each  one 
twisting  the  gathered  end  of  the  blanket  in  opposite  directions.  The 
hot  blanket  is  rapidly  spread  upon  the  other  blankets,  and  the  patient 
snugly  wrapped  in  it  and  successively  in  the  other  blankets.  The 


138        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

danger  of  scalding  patients  has  been  much  overrated  by  inexperienced 
writers;  the  blanket  loses  much  heat  while  being  spread,  indeed  often 
more  than  is  desirable.  If  conscious,  the  patient  soon  experiences 
the  warmth  and  discomfort  of  a  hot  bath  and  ere  long  demands  release. 
There  is  no  stimulus  to  the  heat-producing  functions;  on  the  contrary, 
the  temperature  adjustment  is  in  the  opposite  direction,  perspiration 
of  the  face  ensues,  and  by  capillary  attraction  the  vaporized  water  be- 
gins slowly  to  disappear  in  the  fibres  of  the  blanket.  Instead  of  an 
accumulation,  of  heat  which  results  in  the  cold  wet  pack  from  the 
activity  of  the  compensatory  heat- regulating  function,  we  observe 
after  the  first  impact  of  the  hot  blanket  pack  a  diminished  heat  pro- 
duction. 

The  author  has  demonstrated  to  his  classes  at  the  Post-Graduate 
Medical  School  the  difference  between  the  cold  wet  pack  and  hot 
blanket  pack  in  chronic  nephritis  and  in  the  nephritis  of  pregnancy, 
and  he  has  added  the  testimony  of  the  nurses  to  the  effect  that  when 
the  hot  blanket  pack  is  removed  the  damp  blankets  are  cool,  when 
the  cold  wet  pack  is  removed  the  damp  sheet  is  warm.  In  both  in- 
stances the  effect  would  be  enhanced  by  snugly  enveloping  the  entire 
pack  in  a  rubber  sheet,  to  prevent  vaporization  by  capillary  attraction. 
The  cold  wet  pack  is  therefore  entitled  to  preference.  It  has  not  been 
generally  adopted,  on  account  of  the  legendary  prejudice  against  cold 
applications  to  the  skin  in  nephritis  and  rheumatism.  Even  the  valu- 
able testimony  of  Kussmaul  appears  to  have  failed  to  remove  this 
prejudice. 

Von  Noorden  and  Grodel  *  approve  of  it  in  nephritis  when  good 
reaction  is  provided  for. 

The  author  hopes  to  arouse  more  critical  attention  to  this  val- 
uable procedure  by  this  brief  exposition  of  its  rationale  and  merits. 
In  my  last  service  at  the  J.  Hood  Wright  Hospital,  a  case  of  eclampsia 
in  a  six  months'  pregnancy  was  brought  in  by  the  ambulance.  Rapid 
delivery  produced  a  pause  after  twenty  convulsions;  the  patient  re- 
mained unconscious,  secreting  eight  ounces  of  urine,  mostly  albumin, 
during  the  night.  In  the  presence  of  physicians  from  the  class  of  the 
Post-Graduate  School,  a  wet  pack  at  55°  F.  was  applied.  When  the 
unconscious  patient  was  rolled  into  the  cold  wet  sheet  she  muttered : 
"It  is  wet,  it  is  wet."  After  three  packs  at  four-hour  intervals,  the 
urine  removed  by  catheter  increased,  and  in  a  week  became  normal  in 
quality  and  quantity. 

The  therapeutic  applications  of  the  wet  pack  in  chronic  diseases  are 
extensive,  it  being  valuable  in  all  chronic  cases  in  which  defective  tis- 
sue metamorphosis  is  a  prominent  element,  as  in  diabetes,  rheumatism, 

*  Loc.  cit. 


THE   PRACTICE   OF   HYDEOTHERAPY.  139 

gout,  some  disorders  of  the  digestive  apparatus,  anaemia,  and  chlorosis. 
In  the  functional  neuroses  the  wet  pack  offers  a  means  of  allaying 
irritability,  and,  if  succeeded,  as  it  should  be,  by  a  half-bath,  douche, 
or  other  active  mechanico-hydriatric  procedure,  it  will  refresh  the  ner- 
vous system,  improve  tissue  change  and  the  blood-making  function, 
and  invigorate  the  circulation.  Thus  a  combination  of  effects  results 
which  no  other  procedure  is  capable  of  furnishing.  In  these  cases  it 
may  be  profitably  used  as  a  preparatory  measure  for  the  douche,  instead 
of  the  hot-air  bath.  Indeed,  this  was  its  chief  application  by  Priess- 
nitz  and  the  hydropaths,  who  value  this  procedure  above  all  others. 

"  In  chronic  mental  disorders  the  wet  pack  has  developed  as  a  valu- 
able remedial  agent.*  Two  years  of  almost  constant  use  of  the  cold 
wet  pack  in  carefully  selected  cases  has  demonstrated  its  value  in 
many  forms  of  cerebral  disorder  and  mental  disturbance  hitherto 
deemed  most  intractable. 

Foster  regards  cold  wet  packs  (70°  F.),  general  and  local,  as  "at 
once  safe  and  effectual "  in  maniacal  cases,  complicated  with  "  renal 
symptoms,  often  complete  retention,  marked  reduction  in  daily  excre- 
tion of  urea  (to  one-quarter  normal  amount)  notwithstanding  the  enor- 
mously increased  metabolism;  albumin,  casts,  or  blood  in  urine,  singly 
or  in  combination." 

"  At  the  Toner  Building  quite  a  number  of  cases  of  paresis  in  ad- 
vanced stages  have  been  for  a  considerable  time  under  treatment  at  the 
hands  of  Dr.  Foster.  The  main  therapeutic  agent  has  been  the  cold 
wet  pack.  Dr.  Foster's  conclusions  are  that  "  the  increased  vascular 
tone,  with  consequent  restoration  of  equilibrium  in  vascular  pressure, 
the  relief  of  the  lymph  channels,  and  a  more  normal  supply  of  healthy 
blood  to  the  starving  tissues  are  supposed  to  be  the  causes  contribut- 
ing to  the  mental  calm  and  frequent  refreshing  sleep  which  the  pack 
brings. 

"  The  foregoing  processes  are  all  enhanced  by  massage  following 
the  pack,  especially  effleurage.  The  thermometer  is  always  used  to 
determine  details  of  covering,  need  for  artificial  heat  or  cold. 

"  The  benefit  of  this  active  treatment  is  by  no  means  limited  to  cases 
of  paresis.  Melancholia  and  acute  maniacal  attacks  are  often  relieved, 
but  the  important  question  of  to-day  is:  In  this  hitherto  incurable 
disease  does  it  offer,  even  in  a  small  proportion  of  well-established 
cases,  some  ground  for  hope?  It  can  certainly  do  no  harm  to  try  it  in 
other  hospitals. 

"  In  the  past  year  four  men,  paretics  in  somewhat  advanced  stages 
of  paresis,  have  been  treated  at  the  Toner  Building  by  the  pack  with 
marked  benefit  in  calming  excitement,  promoting  sleep,  relieving  sud- 

*  Government  Report  of  the  Hospital  for  the  Insane,  Washington,  D.C.,  1896. 


140        THE   PRINCIPLES   AND   PRACTICE   OP   HYDRO-THERAPY. 

deuly  occurring  mental  confusion  and  excitement  of  vascular  origin. 
Three  of  these  men  are  now  living,  the  disease  apparently  in  abeyance 
and  the  mental  condition  very  markedly  improved  from  that  at  the 
time  when  the  treatment  was  commenced.  The  fourth  is  dead.  In 
the  fourth  year  of  his  disease,  he  seemed  permanently  bedridden  and 
approaching  the  end.  He  was  removed  to  the  Toner  Building  and 
subjected  to  massage  and  the  pack.  The  improvement  was  as  wonder- 
ful as  it  was  unexpected.  In  two  or  three  months  he  was  again  up 
and  doing  his  work  about  the  ward;  the  lost  motion  had  returned 
and  apparently  much  of  his  former  mental  activity.  Then  suddenly, 
with  no  premonition,  epileptiform  convulsions  returned,  bringing 
a  fatal  termination.  This  man  died  of  paresis,  yet  he  came  nearer  to 
a  recovery  in  the  first  instance  than  any  other  paretic  in  the  hospital." 
Dr.  G.  VV.  Foster,  of  the  Eastern  Maine  Insane  Asylum,  writes, 
January  28th,  1903,  of  his  report  on  the  value  of  the  local  wet  pack 
in  acute  exhaustive  mania  (see  Reports  of  1901  and  1902). 

THE  WET   COMPRESS. 

This  simple  application  is  perhaps  the  most  universally  used  hy- 
driatric  procedure.  In  Germany  it  is  called  the  Priessnitz  Umschlag. 
Although  this  water  quack  doubtless  was  original  in  its  application, 
the  merit  of  its  invention  should  be  assigned  to  Lucas,  the  discoverer 
of  the  wet  pack,  of  which  it  really  is  a  modification.  All  that  has 
been  said  of  the  rationale  of  the  latter  procedure  may  be  applied  to 
the  wet  compress  in  a  minor  degree,  because  of  the  smaller  surface  to 
which  it  is  applied. 

Technique. — Two  or  more  folds  of  old  linen,  thin  or  thick  as  may  be 
required,  and  of  the  necessary  size  and  shape  to  conform  to  the  part 
which  is  to  be  treated,  are  formed  into  a  compress.  Cotton  cloth  is 
objectionable,  because  it  does  not  receive  or  hold  moisture  so  well.  If, 
however,  linen  is  not  available,  the  oldest  and  most  worn  cotton  cloth 
should  be  selected.  The  compress  is  wrung  out  of  water  of  the  re- 
quired temperature  and  is  covered  with  flannel  or  with  a  dry  piece  of 
linen  of  the  same  shape,  but  an  inch  or  two  wider  and  of  sufficient 
length  to  secure  the  wet  cloth  snugly  when  pinned.  It  is  a  sine  <jua 
non  of  the  cold  wet  compress  that  air  be  excluded  from  it,  because  the 
vaporization  of  water  contained  in  it  by  the  warmth  of  the  skin  renders 
the  latter  extremely  sensitive  to  chilling,  which  is  the  usual  result  of 
an  imperfectly  applied  compress.  The  compress  is  renewed  every  hour 
as  a  rule,  but  this  depends  on  each  individual  case.  Before  removal  a 
fresh  compress  should  be  laid  in  readiness.  A  cardinal  rule  to  guide 
in  the  renewal  of  the  compress,  applicable  in  all  cases,  is  that  the  latter 
should  be  warm  before  removal.  If  it  has  not  been  warmed  by  an 


THE   PRACTICE   OF   HYDROTHERAPY. 


141 


hour's  apposition  with  the  skin,  it  must  either  remain  or  be  removed 
without  renewal,  as  directed  below.  As  the  method  differs  in  accord- 
ance with  the  therapeutic  aim,  it  is  necessary  to  enter  into  a  detailed 
description  of  the  compresses  commonly  applied  to  different  parts  of 
the  body. 

The  head  compress  consists  of  a  linen  towel  well  wrung  out  of 
water  at  60°-75°  F.,  which  is  applied  to  the  head  like  a  turban.  It  is 
useful  in  all  procedures  in  which  retrocession  to  the  cerebral  vessels 
may  be  apprehended,  as  in 
wet  packs  and  hot-air  baths. 
It  is  a  commonly  accepted 
idea  among  hydrotherapists 
that  this  application  pre- 
vents uncomfortable  symp- 
toms and  even  dangerous 
congestions.  Whether  this 
purely  empirical  practice  is 
based  on  correct  reasoning 
or  not,  the  wet  turban  cer- 
tainly renders  the  proced- 
ures in  which  it  is  applied 
more  agreeable. 

The  Throat  Compress. — 
Although  this  compress  is 
probably  more  frequently 
applied  than  any  other,  it  is 
remarkable  how  little  its  ra- 
tionale is  understood  and 
how  imperfectly  it  is  ap- 
plied. The  usual  method  is 

to     fold     a    handkerchief    or  FIG.  33.— Imperfect  Throat  Compress. 

napkin  into  a  narrow  band- 
age, dip  it  in  cold  water,  wring  it  out,  and  wind  it  around  the  neck, 
securing  it  by  a  pin  (Fig.  33) .  In  a  very  short  time  the  movements 
of  the  patient  displace  this  bandage,  which  has  been  applied  loosely  to 
prevent  choking,  so  that  it  loses  its  shape,  allowing  air  to  enter  freely 
from  above;  more  or  less  chilling  is  then  produced  and  the  com- 
press dries  rapidly.  As  will  be  seen  in  the  description  of  the 
therapeutic  indications  of  the  throat  compress,  the  object  is  de- 
feated by  this  imperfect  application,  unless  it  is  intended  to  treat 
some  tracheal  or  laryngeal  trouble.  When  intended  for  the  treat- 
ment of  tonsillitis,  diphtheria,  and  other  pharyngeal  affections,  the 
throat  compress  should  be  applied  as  follows  :  A  piece  of  old  thin 
linen,  of  sufficient  length  to  reach  from  below  the  ear  on  one  side  to  the 


t 

142       THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 


same  point  on  tue  ieft,  is  folded  into  a  bandage  of  four  layers.  A  piece 
of  flannel,  eight  by  twenty-four  inches,  provided  with  a  slit  for  each 
ear,  is  also  made  ready-.  These  bandages  are  fitted  by  actual  measure- 
ment to  the  patient's  head,  so  that  they  may  pass  under  the  chin  from 
ear  to  ear.  The  linen  compress  bandage  is  now  wrung  out  of  water  at 

60°  and  laid  upon  the  middle  of 
the  dry  flannel  bandage.  While 
the  wet  bandage  is  placed  under 
the  chin,  the  flannel  bandage  is 
unrolled  from  the  top  of  the 
head  and  passed  over  the  right 
side  of  the  head  (the  right  ear 
being  made  to  protrude  through 
the  slit),  and  then  passed  under 
the  chin  to  the  left  side,  where 
the  left  ear  is  also  allowed  to 
protrude  (the  slit  being  made 
longer  than  actually  needed,  to 
insure  perfect  apposition  of  the 
bandage  and  prevent  pressure 
on  the  ear).  The  entire  band- 
age is  now  firmly  drawn  over 
the  head  and  secured  by  pins 
(Fig.  34).  Two  sets  of  bandages 
are  required — one  being  allowed 
to  dry  while  the  other  is  in  use. 
In  children  and  restless  pa- 
tients, additional  security  is  af- 
forded by  a  circular  turn  around 
the  head,  forming  a  bandage  to 
which  the  throat  compress  may 
be  pinned. 

The  chest  compress  is  pre- 
pared by  cutting  three  folds  of  old  linen  of  a  sufficient  size  to  fit 
the  entire  chest  from  the  clavicles  down  to  the  umbilicus,  with 
arm-holes  in  the  region  of  the  axillae,  made  by  exact  measure 
from  one  axilla  to  the  other,  sufficiently  deep  to  allow  the  upper 
edge  of  the  compress  to  reach  above  the  clavicles  and  admit  of 
the  junction  of  the  flaps  thus  formed  on  each  side,  to  cover  the 
shoulders.  Two  such  jackets,  and  two  pieces  of  closely  woven 
thin  flannel  of  the  same  shape,  but  an  inch  wider  and  longer, 
should  be  provided  and  fitted  to  the  patient.  One  of  the  linen 
compresses  is  rolled  up  and  soaked  in  a  basin  of  water  at  60°  F.,  and 


FIG.  34.— Throat  Compress. 


THE   PRACTICE   OF   HYDKOTHEltAPY. 


wrung  out  so  that  it  remains  quite  damp  without  dripping.  The  flan- 
nel is  now  spread  out  upon  an  even  surface  and  the  wet  compress  put 
upon  it,  so  that  there  remains  an  edge  of  flannel  about  an  inch  wide  all 
around.  Both  are  rolled  together  half-way.  While  the  patient  is  gen- 
tly turned  upon  his  left  side  (Fig.  35),  with  the  precaution  of  not  allow- 
ing any  exertion  on  his  part,  the  compress  is  so  placed  upon  the  bed 
that  the  rolled  part  lies  in  close  proximity  to  the  left  side  of  the  patient 
and  the  lower  edge  of  the  left  slit  is  under  the  left  axilla.  Now  the 


FIG.  35.— Application  of  Chest  Compress. 

patient  is  quietly  turned  upon  his  back,  so  as  to  release  the  rolled-up 
portion.  The  latter  is  now  unrolled,  and  both  edges  of  the  compress 
are  brought  forward  upon  the  front  of  the  chest  and  are  thus  made  to 
envelop  the  latter  snugly.  The  flannel  cover,  which  has  been  allowed 
to  lie  upon  the  bed  during  the  application  of  the  wet  compress,  is  now 
brought  forward  so  as  to  cover  the  latter.  It  is  secured  by  two  safety 
pins  in  front  and  one  pin  upon  each  shoulder  (Fig.  36) . 

As  indicated  above,  this  compress  should  be  made  to  fit  snugly, 
when  wrapped  around  the  chest,  to  prevent  chilling  during  vaporization 
of  the  water.  On  the  other  hand,  it  should  not  be  so  tight  as  to 
embarrass  the  breathing. 

The  compress  should  be  changed  about  once  every  hour,  and  the 


144       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

precaution  previously  mentioned,  to  have  a  fresh  compress  in  readiness 
before  removal,  must  be  observed,  in  order  to  obviate  needless  expo- 
sure of  the  nude  chest,  which  interferes  with  reaction.  Another  im- 
portant precaution  should  be  impressed  upon  the  nurse,  viz.,  to  ascer- 
tain by  inserting  the  finger  beneath  the  compress  if  it  is  thoroughly 
warmed  and  to  avoid  renewal  if  the  linen  is  cool.  So  long  as  the 
rectal  temperature  is  above  99.5°  F.  the  compress  may  be  renewed 
every  hour;  when  it  falls  below  this  point,  it  should  be  allowed  to  re- 


FIG.  36.— Chest  Compress  Complete. 

main  until  dry,  then  removed  when  convenient  and  discontinued  until 
the  rectal  temperature  again  rises.  Thus  a  rotation  is  kept  up  every 
half-hour  or  hour,  as  the  case  may  require,  night  and  day,  unless  the 
patient  is  asleep.  The  water  in  the  basin  should  be  renewed  each 
time,  and  the  compress  rinsed  off  in  another  basin  before  it  is  rolled 
up  for  soaking.  In  order  to  insure  thorough  cleanliness  and  prevent 
furuncles  by  furthering  asepsis,  two  sets  of  compresses  are  required 
to  admit  of  changing,  and  each  compress  should  be  boiled  once  ^n 
twenty-four  hours,  as  in  the  other  forms  of  this  procedure.  A  very 
prevalent  error  is  committed  unwittingly  by  nurses  in  their  commend- 
able zeal  for  cleanliness,  viz.,  the  covering  of  the  compress  with  oiled 
silk  or  other  waterproof  material.  The  latter  would  convert  the  wet 
compress  into  a  poultice — in  surgery  termed  a  wet  dressing.  Inas- 


THE   PRACTICE   OF   HYDROTHERAPY.  145 

much  as  the  chief  aim  of  the  wet  compress  is,  first,  stimulation  by  the 
thermic  excitation,  then  hyperaemia  by  reaction,  and  it  is  desired  to 
reduce  the  latter  slowly  by  evaporization  through  the  flannel  for  anti- 
thermic effect,  the  impervious  covering  would  defeat  the  object.  Un- 
less nurses  have  been  specially  instructed,  they  will  surely  use  a  water- 
proof cover,  especially  over  an  abdominal  or  chest  compress. 

The  technique  of  the  procedure  has  been  entered  into  with  a  detail 
that  may  seem  needless.  As  will  be  shown  later,  these  details  insure 
precision,  and  upon  their  exact  execution  may  depend  success  or  fail- 
ure. The  physician  should  himself  supervise  the  first  application  of 
all  compresses,  just  as  he  should  supervise  the  first  Brand  bath  in 
typhoid  fever.  A  skilled  nurse  can  apply  these  compresses  with  a 
minimum  of  disturbance. 

There  is  need,  too,  of  individualization.  In  the  average  case  a 
temperature  of  60°  F.  will  be  appropriate.  Should  the  patient  evince 
stupor  or  muttering  delirium,  a  lower  temperature  should  be  adopted, 
and  the  chest  should  receive  one  or  more  dashes  of  colder  water  before 
renewal  of  each  compress.  The  same  procedure  is  indicated  in  bron- 
cho-pneumonia, when  the  bronchi  are  blocked  by  secretions  or  cyanosis 
exists. 

'  When  in  adynainic  conditions  the  compress  does  not  warm  readily 
and  the  skin  remains  cool  after  expiration  of  an  hour,  the  linen  cloths 
should  be  removed  and  the  chest  wrapped  in  flannel  alone  until  the 
skin  becomes  warm.  Then  the  compress  should  be  well  wrung  out  of 
water  at  60°  and  applied  after  gentle  friction.  Such  a  compress,  if 
snugly  applied,  improves  cardiac  action,  as  evidenced  by  return  of 
pink  hue  to  the  finger-nails.  Cautious  abstention  from  and  resump- 
tion of  cold  procedures  as  indicated,  furnish  a  simple  but  potent 
weapon  against  adynamic  conditions,  especially  in  the  pneumonias  of 
children.  , 

A  higher  temperature  than  60°  F.  may  be  used  if  there  be  much 
jactitation,  insomnia,  or  excitability.  In  the  latter  event  great  benefit 
will  accrue  from  allowing  the  compress  to  remain  two  hours  and  moist- 
ening it  more  thoroughly  before  application,  thus  converting  the  com- 
press into  a  soothing  fomentation  that  is  not  relaxing  like  a  poultice. 

The  rationale  of  this  chest  compress  will  be  fully  discussed  in  an 
article  on  pneumonia. 

An  excellent  chest  bandage  has  been  devised  by  Winternitz  and 
termed  by  him  "  crossbinder"  ("Kreuzband").  A  bandage  made  of 
linen  2$  to  3  inches  wide  and  16  to  20  inches  long,  two  folds  thick, 
is  wrung  out  of  water  at  60C-70°  and  prepared.  The  left  end  of  this 
bandage  is  placed  on  the  back  below  the  left  shoulder ;  it  is  now  car- 
ried forward  across  the  chest,  turned  around  the  latter,  and  brought 
10 


146        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

forward  across  the  chest  in  front  over  the  left  shoulder,  and  again 
around  the  chest  below.  This  is  covered  with  flannel.  The  author 
prefers  the  vest-shaped  compress  described  above  in  pneumonia,  be- 
cause it  may  be  applied  with  a  minimum  of  disturbance,  while  the 
cross  binder  requires  a  sitting  posture. 

The  abdominal  compress  consists  of  a  piece  of  linen  in  three  folds, 
of  sufficient  size  to  reach  from  the  sternum  to  the  pubis  and  lap 
over  on  each  side  of  the  abdomen.  This  is  wrung  out  of  water  at  60°- 
70°  F.,  and  held  in  position  by  a  flannel  bandage  a  little  wider  and 
long  enough  to  reach  around  the  body,  being  snugly  secured  in  front  by 
safety  pins. 

When  a  change  of  this  bandage  is  necessary  the  flannel  is  simply 
opened,  the  fresh  compress  applied,  and  the  flannel  again  secured. 
When  the  latter  becomes  so  damp  as  to  convey  moisture  to  the  bed 
clothing,  it  should  be  changed.  It  is  always  well  to  keep  two  or  more 
sets  of  compresses  on  hand.  Each  compress  should  be  boiled  once  a 
day  for  fifteen  minutes,  to  prevent  septic  furunculosis.  The  author  is 
cognizant  of  an  instance  in  which  a  most  able  physician  became  preju- 
diced against  these  compresses,  because  his  hospital  patient,  a  de- , 
preciated  individual,  suffered  from  painful  furuncles  while  convalescing 
from  a  severe  attack  of  pneumonia  treated  with  compresses.  If  the 
exact  technique  here  described  be  followed,  no  untoward  circumstances 
will  occur.  The  nurse  should  be  cautioned  to  provide  a  dry  flannel 
cover  to  prevent  the  patient's  clothing  and  bed  clothing  from  becoming 
damp.  Rubber  sheets  must  be  avoided ;  they  prevent  evaporation  and 
defeat  the  object  of  the  compress,  which  is  cooling  and  secondarily 
stimulating.  An  extra  sheet  folded  several  times  and  placed  under  the 
trunk  of  the  patient  is  the  best  protection.  This  precaution  applies  to 
all  compresses. 

The  Neptune  girdle  consists  of  a  bandage  of  coarse  linen,  suffi- 
ciently large  to  cover  the  entire  lower  part  of  the  trunk,  from  the 
ensiform  cartilage  to  the  pubes,  and  long  enough  to  reach  around  the 
entire  trunk  and  afford  a  double  cover  for  the  abdomen.  This  is  wrung 
out  of  water  usually  of  60°-75°,  snugly  wrapped  around  the  body  sev- 
eral times,  covered  with  another  linen  or  a  flannel  bandage  and  secured 
by  pins.  These  bandages  are  changed  twice  or  three  times  in  twenty- 
four  hours,  the  part  being  washed  with  cold  water  each  time  before  a 
'fresh  bandage  is  applied.  This  is  the  so-called  Priessnitz  Umschlag 
of  the  Germans,  which  the  author  rarely  has  had  occasion  to  use,  ex- 
cept in  chronic  cases.  In  the  latter  it  may  be  renewed  three  times  in 
twenty-four  hours,  the  parts  being  rubbed  with  a  cold  damp  towel  pre- 
vious to  each  application.  Priessnitz  was  wont  to  point  with  pride  to 
the  purulent  furuncles  produced  by  his  "  Umschlag,"  claiming  that  its 


THE   PRACTICE   OF    HYDROTHERAPY.  147 

power  to  remove  "  bad  humors  "  was  thus  clearly  demonstrated.  These 
boils  were  clue  to  iufection  of  points  abraded  by  the  coarse  wet  linen 
he  used,  an  infection  that  was  promoted  by  the  continuation  of  the 
same  compress  for  long  periods. 

The   Combination   Compress  of  Winternitz. — This  is  a  modification 
of  the  Neptune  girdle,  which  is  applied  in  certain  conditions  mentioned 


FIG.  37.— The  "  Winternitz  Combination  "  Compress.    (From  "  Blatter  fUr  klinischo 
Hydrotherapie.") 

below.  He  applies  the  wet  compress  as  usual,  but  lays  a  Leiter  or 
rubber  coil  upon  the  epigastric  region,  and  covers  it  with  a  dry  bandage. 

A  bucket  of  very  hot  water  being  in  readiness  upon  a  shelf  or  other 
high  point  near  the  bed,  the  afferent  tube  of  the  coil  is  connected  with 
the  hot-water  supply,  which  is  made  to  flow  through  the  coil  into  a 
vessel  connected  with  the  efferent  tube  (Fig.  37). 

Rationale  of  the  Combination  Compress. — The  cold  wet  compress 
enveloping  the  trunk  from  above  the  base  of  the  ensiform  cartilage  to 
the  pelvis  produces,  like  all  cold  procedures,  an  anaemic  condition  of 
the  skin  beneath.  The  cutaneous  vessels  are  contracted,  the  periph- 
eral nerves  are  irritated,  and  the  respiration  is  deepened.  Keaction 
quickly  ensues ;  the  parts  grow  warm,  the  vessels  become  dilated  in  a 
tonic  manner,  and  the  circulation  is  rendered  more  active.  Beneath 
the  part  which  is  covered  by  the  coil  containing  hot  water,  reaction  is 
more  rapid  and  the  part  becomes  warmer  and  hypereemic.  As  a  con- 
sequence the  epigastric  region  is  covered  by  a  warm  moist  vapor;  a 
decided  calming  of  the  cutaneous  nerves  ensues;  this  is  doubtless 
transmitted  by  reflex  through  peripheral  ganglia  to  the  underlying 
parts,  which  are  at  the  same  time  rendered  less  congested  by  reason  of 
the  derivative  effect  to  the  skin. 


148       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

•. 

This  compress  has  been  used  with  advantage  in  obstinate  vomit- 
ing, organic  or  functional,  even  in  the  vomiting  of  pregnancy  j  in  gastric 
catarrh,  hyperacidity,  ulcer  of  the  stomach;  also  in  dysmenorrhcea 
and  pleuritis  when  applied  instead  of  poultices;  in  typhlitis,  pneu- 
monia, meningitis.  In  the  anorexia  which  is  so  common  in  phthisis 
and  other  wasting  disease,  it  is  highly  lauded  by  Wendringer,*  who 
cites  several  striking  histories.  Like  Winternitz  himself,  he  induced 
patients  to  take  large  quantities  of  food  during  the  application  of  this 
compress  and  coil,  and  often  the  food  was  retained  after  failure  of  all 
other  remedies  to  effect  this  result. 

The  technique  of  the  ivet  compress  differs  according  to  the  object 
aimed  at,  compresses  being  applied  according  to  the  latter. 

The  antiphlogistic  compress  is  composed  of  two  layers  of  old  and 
thin  linen,  which  are  dipped  into  water  not  over  60°  F.,  and  applied 
snugly  over  the  inflamed  part.  It  is  not  intended  to  influence  the  lat- 
ter when  the  inflammation  is  deeply  seated.  Its  therapeutic  action  is 
due  to  a  contraction  of  the  inflamed  vessels,  which  contraction  must  be 
maintained  by  frequent  renewal  and  by  avoiding  any  covering;  other- 
wise the  compress  would  soon  be  converted  by  the  heightened  tempera- 
ture of  the  inflamed  part  into  a  fomentation  or  poultice,  the  effect  of 
which  would  be  contrary  to  that  desired.  The  tonicity  of  the  vessels 
is  enhanced  by  the  impact  of  the  cold  conveyed  by  the  moist  linen ; 
the  part  becomes  anaemic,  and  the  circulation,  which  has  been  acceler- 
ated by  the  inflammatory  process,  is  diminished.  The  process  being 
inhibited  by  the  continuous  cold,  because  the  migration  of  white  cells 
is  interrupted,  exudations  are  prevented,  and  the  nutrition  of  the  part 
is  enhanced  by  the  tonic  stimulation  induced  by  cold.  An  exact  adapta- 
tion of  the  latter  to  the  therapeutic  indication  is,  however,  essential,  as 
in  all  other  hydriatric  procedures ;  for  if  the  temperature  of  the  water  be 
raised  beyond  75°,  or  if  the  cold  be  not  maintained,  the  contraction  of 
the  cutaneous  vessels  will  be  followed  by  dilatation,  and  the  antiphlo- 
gistic effect  will  be  inhibited.  If,  on  the  other  hand,  the  temperature 
of  the  water  be  too  low,  40°  to  50°,  the  peripheral  nerves  and  vessels 
may  be  paralyzed  by  its  continuous  application,  or,  if  the  latter  be  in- 
termittent, dilatation  must  follow,  which  would  not  further  our  thera- 
peutic aim,  but  rather  oppose  it  by  producing  an  afflux  of  blood  to  the 
already  hypersemic  skin.  For  the  purpose  of  cooling  inflamed  cutane- 
ous .parts  near  the  surface,  a  compress  moistened  with  water  at  from 
50°  to  60°  F.  should  be  applied;  the  latter  may  be  frequently  renewed 
by  allowing  cold  water  to  drip  upon  the  linen,  the  excess  being  re- 
ceived on  a  thickly  folded  towel  lying  beneath  the  part;  or,  what  is 
still  better,  ice  bags,  or  a  coil  through  which  cold  water  is  made  to 
*Monatsheftc  fur  Wasserheilkunde,  December,  1894. 


THE   PRACTICE   OF   HYDKOTHEBAPY.  149 

flow  continuously,  may  be  applied  over  the  cold  compress  for  the  pur- 
pose of  maintaining  the  low  temperature  of  the  latter. 

Cooling  Deep- Seated  Parts. — Contrary  to  the  commonly  prevalent 
idea  that  cooling  applications  made  to  the  cutaneous  surfaces  penetrate 
deeply  if  sufficiently  cold  and  prolonged,  the  author  is  convinced  that 
the  heat-regulating  machinery  of  the  body  is  immediately  called  into 
action  for  the  purpose  of  resisting  the  invasion  of  cold  into  the  interior 
and  that  it  thus  frustrates  the  object  in  view.  The  application  of  ice 
bags  in  pneumonia,  pericarditis,  peritonitis,  gastritis,  appendicitis,  etc., 
is  so  universal  that  the  author  opposes  this  practice  with  great  hesitance 
and  reluctance.  Due  consideration  of  the  contradictory  findings  of 
various  experimenters  and  the  teaching  of  practical  experience  may 
convince  the  reader,  as  it  has  convinced  the  author,  of  the  fallacy  of 
the  established  practice.  The  anaesthetic  effect  of  a  hot  poultice  or  an 
ice  bag  cannot  be  denied,  but  that  such  external  applications  can  affect 
the  lungs  or  appendix  to  any  appreciable  extent  is  doubtful.  Dr.  Henry 
C.  Coe  has  informed  me  that  he  observed,  while  acting  as  pathologist  to 
the  Woman's  Hospital  several  years  ago,  no  effect  upon  peritonitis,  after 
the  most  energetic  use  of  the  ice  coil,  in  any  of  his  post-mortem  exam- 
inations. In  operations  on  the  living  subject  he  has  never  observed  the 
slightest  effect  of  previously  applied  cold  applications  upon  the  hyper- 
vascular  condition  in  the  peritoneum.  This  is  the  experience  of  all 
laparotomists.  The  action  of  cold  on  temperature  has  been  fully  set 
forth  and  therefore  need  not  be  reiterated.  In  connection  with  and  in 
support  of  this  physiological  proof  the  excellent  experiments  of  Dr. 
W.  Gilman  Thompson  *  may  be  of  interest.  Dr.  Thompson  etherized 
several  dogs,  shaved  the  abdominal  wall,  and  made  a  small  incision  on 
one  side  of  the  latter  through  which  a  long-stemmed  thermometer  was 
passed  to  the  opposite  side  of  the  abdomen.  When  the  thermometer 
was  felt  pressed  up  beneath  the  skin  an  ice  coil  was  applied  for  an 
hour.  So  long  as  the  dog's  circulation  was  maintained,  the  thermom- 
eter remained  uninfluenced,  but  as  soon  as  the  dog  was  killed  the  tem- 
perature of  the  abdominal  cavity  began  to  fall  very  rapidly.  Heat 
applied  by  poultices  showed  a  corresponding  behavior.  In  a  cadaver 
with  an  abdominal  wall  not  over  one-half  or  three-quarters  of  an  inch 
thick  the  cold  of  an  ice  coil  penetrated  very  slowly,  but  finally,  after 
three-quarters  of  an  hour,  it  caused  a  diminution  of  intra-abdominal 
temperature  of  25°  F.  If  a  cold  coil  be  placed  on  the  abdomen  of  a 
typhoid  patient  and  water  of  32°  or  34°  F.  be  allowed  to  run  through 
it,  a  thermometer  placed  between  the  coil  and  the  abdominal  wall  would 
average  64°  to  70°  F.  Hence,  so  long  as  the  circulation  is  fairly  good, 
it  appears  to  be  impossible  to  influence  materially  the  deep-seated  ves- 

*" International  Clinics,"  1892. 


150        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY.      * 

sels  by  external  local  contrasts  of  temperature ;  certainly  it  is  impos- 
sible to  control  hemorrhage  by  these  means,  and,  practically,  Dr. 
Thompson  has  never  seen  any  benefit  from  such  attempts.  If  any 
result  ensues  it  must  come  through  very  circuitous  reflex  action. 

Results  differing  from  those  reported  by  Dr.  Thomson  are  discussed 
by  Rob.  Heintz  (Deutsche  med.  Zeitung,  March  20th,  1901)  before  the 
Congress  for  Internal  Medicine  in  Berlin.  He  starts  by  taking  it  for 
granted  that  vessels  in  deep-seated  parts  may  be  influenced  by  cold 
and  heat,  moisture,  wet-cups,  etc.  He  claims  to  have  ascertained,  by 
means  of  a  thermo-electric  apparatus  in  the  pleural  cavity  of  rabbits 
and  dogs,  whose  chest  walls  are  thicker  than  those  of  man,  that  cold 
compresses  placed  upon  the  shaved  skin  diminished  the  pleural  tem- 
perature from  one-tenth  to  one  degree,  and  that  the  ethyl-chloride  spray 
upon  the  shaved  skin  reduced  the  internal  temperature  10°  C.  Oppo- 
site results  followed  applications  of  heat.  Esmarch's  observation  on 
carious  cavities  also  have  shown  reduction  of  temperature  under  super- 
ficial cold.  This  result  is  easily  explained :  the  ribs  and  other  bones 
are  not  filled  with  warm  blood  as  are  the  soft  parts  and  therefore  form 
better  conductors  and  more  feeble  antagonism  to  the  penetration  of 
cold.  This  anatomical  fact  may  explain  the  cooling  effect  upon  the 
heart,  which  Sitva  claims  to  have  produced  with  the  precordial  ice  coil. 
Some  interesting  experiments  are  reported  by  Silex*  to  demonstrate 
the  fallacy  of  the  views  entertained  on  the  application  of  cold  for  in- 
flammatory conditions.  He  anaesthetized  the  conjunctiva  with  tropo- 
cocaine.  The  temperature  (ascertained  by  a  thermo-electric  apparatus) 
of  the  healthy  conjunctiva  was  1.51°  C.  less  than  that  of  the  mouth, 
while  in  cases  of  conjunctivitis,  corneal  ulcers,  etc.,  that  of  the  con- 
junctiva was  0.89°  C.  less;  inflamed  eyes  were  only  0.62°  C.  warmer 
than  healthy  eyes.  In  a  few  cases  of  iritis  the  conjunctival  tempera- 
ture was  0.92°  C.  higher  than  the  oral.  The  application  of  cold  com- 
presses to  the  lids  increased  the  temperature  of  the  conjunctiva; 
warmth  diminished  it.  In  a  case  of  gonorrhoeic  blennorrhoea  the  tem- 
perature of  the  conjunctiva  increased  2.24°  C.  after  ice  compresses  were 
applied  for  ten  minutes.  His  experiments  on  animals  showed  an  increase 
of  temperature  in  the  organs  over  which  ice  had  been  applied.  The 
findings  of  Silex  are  contradicted  by  Mathes  and  Giese,  f  whose  experi- 
ments show  a  distinct  increase  of  conjunctival  temperature  after  hot  and 
decrease  after  cold  compresses  over  the  lids.  And  confirmation  of  the 
latter  is  furnished  by  Hertel,J  who  found  not  only  direct  conduction 
\ 

*"Ueber  kalte  und  warme  Umschlage,"  MDnchener  medicinische  Wochen- 
schrift,  1893,  No.  4. 

f  Knapp :  Schweigger's  Archiv,  1897. 

\  Archiv  fiir  Ophtbalmologie,  1899,  No.  1,  p.  125. 


THE   PRACTICE   OF   HYDROTHERAPY. 


151 


through  the  thin  lid  to  the  conjunctiva,  but  also  to  and  through  the 
globe  of  the  eye.  Hertel  attributes  this  conduction  very  justly  to  the 
thinness  of  the  lid,  in  which  scarcely  any  fat  is  found,  and  to  the  watery 
contents  of  the  ocular  globe.  Both  cold  and  heat  acted  as  anodynes 
in  superficial  keratitis,  iritis,  and  cyclitis,  by  reason  of  their  anaesthetic 
effect  upon  the  sensory  terminals. 

The  experiments  of  Silex  and  Giese  were  made  with  a  thermo- 
electric apparatus,  those  of  Hertel  with  a  thermometer. 

Cooling  applications  to  the  head  have  long  been  in  use  in  meningitis 
and  other  hyperaemic  conditions  within  the  cranial  cavity.  Esmarch 
has  shown  that  cold  may  be  conveyed 
through  bone.  This  is  probably  be- 
cause the  circulation  in  the  cranial 
bones  not  being  sufficiently  active  to 
resist  the  invasion  of  cold  into  the  in- 
terior they  rather  aid  in  conducting  it 
to  the  meninges.  The  ordinary  ice 
bags  used  for  this  purpose  are  clumsy 
and,  despite  their  popularity,  inade- 
quate. Aside  from  their  weight  and 
roughness,  there  is  always  more  or 
less  condensation  on  the  outside  of 
the  bag,  which  causes  wetting  of  the 
pillow  and  conduces,  in  subfebrile  con- 
ditions, to  rheumatic  pains.  An  im- 
provement on  the  ice  bag  is  a  wet 
compress  of  two  or  three  thicknesses, 
which  is  made  to  cover  the  head  (pref- 
erably after  the  hair  is  clipped)  and 
which  is  held  in  place  by  a  rubber-coil 
cap  (Fig.  38).  Through  the  latter  ice 
water  may  be  made  to  flow  for  the  purpose  of  maintaining  the  continu- 
ous low  temperature  desired. 

II.  The  stimulating  wet  compress  is  most  frequently  used.  It 
consists  of  two  or  three  folds  of  old  but  coarse  linen,  whicli  is  well 
Avrung  out  of  water  at  about  60°,  covered  by  a  flannel  or  by  another 
linen  bandage,  and  allowed  to  remain  until  it  is  warmed  thoroughly  in 
acute  cases  or  until  it  is  dry  in  chronic  cases. 

Not  infrequently  the  stimulating  compress  does  not  warm  up;  the 
patient  feels  chilly  and  uncomfortable.  The  compress  need  not  be 
discontinued  on  that  account.  It  is  necessary  only  to  leave  it  on  until 
it  is  thoroughly  warm  and  to  apply  cold  water  with  friction  before  the 
compress  is  reapplied  in  these  cases,  for  the  purpose  of  inciting  the 


FIG.  38.— Head  Compress. 


152        THE   PRINCIPLES   AND   PRACTICE   OF    HYDROTHERAPY. 

activity  of  cutaneous  vessels  by  this  thermic  irritation  and  thus  en- 
hancing reaction.  The  same  purpose  may  be  accomplished  by  using 
much  colder  water  for  the  compress  and  wringing  the  latter  more  thor- 
oughly. This  is  contrary  to  the  prevalent  idea,  which  is  based  on  the 
error  that  cold  water  depresses  and  warm  water  stimulates.  A  stimu- 
lating cold  compress  must  never  be  removed,  if  it  is  not  warm.  For  this 
reason  it  is  well  to  discontinue  it  in  acute  infectious  diseases  when  the 
rectal  temperature  falls  to  99.5°  F. 

Rationale  of  the  Wet  Compress. — The  usual  effect  of  cold  upon  the  cu- 
taneous vessels  is  at  once  produced;  they  contract  by  reason  of  the 
stimulus  from  the  cold;  the  part  becomes  cold,  but  very  soon,  accord- 
ing to  the  temperature  of  the  water  and  the  reactive  capacity  of  the 
patient,  an  active  hyperaemia  ensues — the  tonic  dilatation  so  frequently 
referred  to  above.  Now  the  compress  becomes  heated  by  the  afflux  of 
arterial  blood  beneath  it ;  the  further  dissipation  of  heat  being  inhibited, 
it  accumulates  underneath  the  compress,  which  gradually  attains  the 
temperature  of  the  part — the  dry  covering  preventing  rapid  evaporation. 
Thus  heat  is  accumulated  until  the  compress  becomes  dry,  so  long  as 
the  application  is  snugly  made;  the  vessels  receive  an  active  afflux  of 
blood,  local  tissue  metamorphosis  is  enhanced,  and  diseased  conditions 
are  removed  by  the  improved  blood  supply.  By  the  repetition  of  the 
cold  compress  there  is  produced  an  alternating  effect,  cold  succeeded  by 
warmth,  which  eventually  increases  the  quantity  of  blood  circulating  in 
the  cutaneous  vessels,  and  must  also  affect  the  circulation  in  the  under- 
lying muscles,  because  the  vessels  of  the  latter  are  in  direct  connection 
with  the  former.  Moreover,  these  vessels  are  also  connected  with  the 
deeper  circulation,  as  is  demonstrated  by  the  enlargement  of  the  abdom- 
inal veins  which  is  often  noticed  in  persons  suffering  from  cirrhosis  of  the 
liver.  As  has  been  shown  in  explaining  the  rationale  of  other  cold 
procedures,  whenever  the  cutaneous  vessels  are  contracted  a  compensa- 
tory dilatation  of  the  deeper  vessels  ensues.  Thus  the  deeper  parts  lying 
underneath  the  compress  receive  a  sudden  afflux  of  blood  during  the 
first  impact  of  the  cold  compress,  and  when  the  cutaneous  vessels  dilate 
under  the  reaction  which  follows  the  vessels  in  the  deeper  parts  are 
again  narrowed.  This  active  fluxion  between  the  vessels  of  the  deep 
and  superficial  parts  must  exert  a  powerful  influence  upon  the  former. 
Moreover,  the  irritation  of  the  cutaneous  nerve  endings  by  the  sudden 
impact  of  cold,  and  the  subsequent  calming  of  their  irritation  by  the 
warming  up  of  the  part  and  its  being  bathed  in  a  vapor,  are  conveyed 
to  the  central  nervous  system  and  thence  reflected  upon  the  organs  de- 
pending upon  the  latter  for  innervation.  We  need  refer  only  to  the 
effect  of  the  cold  compress  upon  the  inspiration,  which  is  deepened,  and 
upon  the  pulse,  which  is  slowed. 


THE    PRACTICE   OF   HYDROTHEEAPY.  153 

A  compress  wrung  out  of  Lot  water  would  produce  a  primary  con- 
traction of  the  cutaneous  vessels,  which  would  be  followed  by  their  re- 
laxation and  loss  of  tone,  while  the  underlying  parts  would  become 
hyperaernic.  But  in  this  instance  the  primary  thermic  effect  upon  the 
central  nervous  system  would  be  almost  nil,  while  the  soothing  effect 
upon  the  peripheral  nerve  endings  would  be  decided. 

Both  cold  and  warm  compresses  produce  effects  upon  the  composi- 
tion of  the  blood  in  parts  lying  beneath  them  and  upon  distant  parts, 
also  upon  their  temperature. 

Effect  of  Different  Compresses  upon  the  Blood. — Winternitz  has 
investigated  the  local  action  of  stimulating  and  warm  compresses.* 
He  found  that  the  composition  of  the  blood  after  all  thermic  procedures 
differs  according  to  the  locality  of  the  part  from  which  the  blood  speci- 
men is  obtained,  whether  it  lies  near  or  upon  the  periphery  or  near  the 
centre  of  the  body.  There  was  an  increase  of  haemoglobin  in  the  blood 
cells  and  in  the  specific  gravity  of  the  blood  as  it  approaches  toward  the 
central  parts  of  the  body,  the  blood  from  the  finger  tip  or  ear  lobe  be- 
ing less  rich  than  that  of  the  skin  over  the  abdomen  or  chest.  The 
leucocytes  did  not  obey  this  rule;  they  were  sometimes  increased  at 
the  periphery  and  sometimes  at  central  points.  After  cold  or  warm 
compresses  a  great  change  in  composition  ensued  in  the  blood  of  the 
parts  to  which  they  were  applied  and  in  the  parts  untouched  by  them. 

The  observation  was  almost  regularly  made  that  after  cold  an  in- 
crease of  erythrocytes,  haemoglobin,  and  specific  gravity  ensued.  When 
cold  was  applied  to  the  entire  surface,  the  leucocytes  were  generally 
increased;  local  applications  sometimes  increased  and  sometimes  dimin- 
ished them.  Decrease  always  resulted  after  cold  sitz  baths. 

An  examination  into  the  effects  of  the  so-called  stimulating  com- 
presses (linen  well  wrung  out  of  cold  water  and  covered  snugly  with 
flannel)  resulted  as  follows :  Before  application,  blcod  from  the  finger 
tip  showed  95  per  cent  of  haemoglobin,  and  5,800,000  red  and  10,000 
white  corpuscles;  blood  from  the  skin  over  the  calf  of  the  leg  showed 
before  the  experiment  105  per  cent  of  haemoglobin,  and  6,400,000 
red  and  8,800  white  corpuscles.  After  a  stimulating  compress  had 
been  in  position  one  and  one-half  hours  around  the  leg,  the  blood 
was  again  examined  and  compared  with  that  from  the  finger  tip.  This 
showed  a  loss  of  5  per  cent  of  haemoglobin  and  of  500,000  red  corpus- 
cles, and  that  the  leucocytes  were  also  diminished.  In  the  blood  taken 
from  the  leg  at  a  point  where  the  compress  had  lain,  the  haemoglobin 
had  risen  to  115  per  cent,  the  erythrocytes  had  increased  1,000,000  to 
the  cubic  centimetre,  and  the  leucocytes  had  increased  800.  The  change 

*  Blatter  f  ur  klinische  Hydrotherapie,  1894. 


15-1       THE   PRINCIPLES   AXD   PRACTICE   OF   HYDROTHERAPY. 

produced  by  the  stimulating  compress  was  most  noticeable  in  the  in- 
crease of  red  blood  cells,  just  as  we  find  in  congested  parts. 

In  order  to  ascertain  the  effect  of  warm  compresses,  the  composi- 
tion of  blood  from  the  finger  tip  and  from  the  skin  over  the  abdomen 
was  studied.  The  finger-tip  blood  showed  95  per  cent  of  haemoglobin 
and  5,300,000  red  cells;  the  blood  from  the  abdominal  skin  showed 
120  per  cent  of  haemoglobin  and  7,000,000  red  cells;  while  the  leuco- 
cytes were  7,000,  about  the  same  in  both  specimens.  After  a  warm 
compress  (127°  F. )  had  lain  one  and  one-half  hours  upon  the  abdomen 
a  comparison  was  again  instituted,  showing  that  in  the  blood  from  the 
finger  tip  the  haemoglobin  had  increased  10  per  cent  and  the  red  cells 
900,000;  the  leucocytes  had  also  increased  1,000.  But  the  blood 
taken  from  the  abdominal  skin  beneath  the  cataplasm  had  lost  22  per 
cent  of  its  haemoglobin  and  2,500,000  of  its  red  cells,  while  the  leuco- 
cytes were  doubled. 

From  Professor  Brieger's  hydrotherapeutic  institute  of  the  Berlin 
University  his  assistants,  Laqueur  and  Loewenthal,  report  an  investi- 
gation of  the  influence  of  local  hydrotherapeutic  procedures  upon  the 
composition  of  the  blood.  The  authors  claim  that  they  discovered  no 
positive  difference  between  the  effect  of  stimulating  cold  and  hot  com- 
presses upon  the  composition  of  the  blood,  either  at  the  point  of  appli- 
cation or  elsewhere.  The  leucocytes,  however,  ivere  always  increased 
at  the  point  of  application,  whether  cold  or  hot,  while  they  were  dimin- 
ished at  distant  points. 

This  experiment  demonstrates  that  the  choice  of  temperature  is  not 
indifferent  when  wet  compresses  are  indicated.  Although  the  patient's 
sensations  offer  a  fair  guide,  the  rationale  of  cold  and  warm  compresses 
enables  us  to  adapt  them  to  the  actual  requirements  of  each  case.  For 
antiphlogistic  purposes  it  may  be  safely  held  that  in  the  early  stage  of 
congestion  cold  applications  are  useful  so  long  as  the  circulation  in  the 
affected  part  is  still  open,  which  is  indicated  by  the  turgor.  But  when 
the  parts  assume  a  cyanotic  hue,  when  leucocytes  have  begun  to  ad- 
here in  large  numbers  to  the  vessel  wall  and  emigration  has  become 
active,  applications  of  warmth  further  the  latter  and  hasten  suppura- 
tion when  it  is  unavoidable.  The  cold  compress  diminishes  congestion, 
retards  leucocytosis  and  emigration  of  white  cells,  while  the  warm 
applications  have  the  contrary  effect,  each  being  most  useful  in  the 
respective  stage  of  inflammation. 

The  wet  compress,  covered  by  an  impermeable  covering,  known  in 
surgical  parlance  as  "  wet  dressing,"  which  is  retained  for  a  more  or 
less  prolonged  period  over  diseased  parts,  and  is  superior  to  the  poul- 
tice by  reason  of  its  simplicity,  capacity  for  holding  antiseptics,  and 
by  its  lightness,  readily  demonstrates  the  difference  between  a  properly 
and  improperly  applied  wet  compress,  and  the  capacity  of  modification 


THE   PRACTICE   OF   HYDROTHERAPY.  155 

possessed  by  the  latter  in  adapting  it  to  the  therapeutic  indications  of 
the  individual  case. 

The  antiphlogistic  effects  of  cold  compresses  are  readily  explained 
by  the  results  of  Genzuier's  experiments  *  upon  local  blood  letting.  He 
came  to  the  conclusion  that  the  favorable  effect  of  bleeding  upon  the  in- 
flamed parts  beneath  was  ascribable,  not  to  their  becoming  more  anaemic, 
but  to  the  fact  that  the  blood  stream  became  more  rapid,  and  thus  the 
corpuscles  which  had  adhered  to  the  vessel  walls  were  loosened  and 
driven  into  the  general  circulation.  The  fluxion  therefore  which  the 
application  of  cold  or  warm  compresses  produces  in  parts  below  them 
is  the  true  cause  of  the  changes  in  the  latter  when  inflamed.  Thus 
may  the  old  theory  of  derivation  be  satisfactorily  explained. 

This  effect  of  cold  applications  may  be  called  into  action  in  some 
local  inflammations  in  which  the  parts  appear  cyanotic  and  it  is  im- 
portant to  prevent  impending  suppuration.  Here  hot  compresses  or 
cataplasms  are  also  useful  to  arouse  the  surface  circulation ;  as  they  cool 
off  they  widen  the  deeper  vessels  and  thus  re-establish  the  circulation 
which  has  become  stagnant.  This  being  accomplished,  cold  compresses 
may  succeed  the  hot,  in  order  to  limit  leucocytosis  and  by  fluxion  re- 
move stagnant  corpuscles.  It  is  evident  that  by  the  exercise  of  sound 
judgment  the  proper  temperature  of  the  compress  may  be  nicely 
adjusted  to  each  case. 

Effect  of  Compresses  upon  Temperature. — The  effect  of  the  stimu- 
lating compresses  upon  the  temperature  of  the  part  has  been  studied  by 
Winternitz,  Pollak,  and  others. f  During  the  first  five  minutes  the 
changes  vary  from  1°  to  -|°  C.  The  cutaneous  temperature  reached  its 
maximum  most  rapidly  under  a  dry  bandage  of  wadding,  in  five  min- 
utes. Under  a  wet  compress  of  104°,  without  cover,  the  temperature 
began  to  sink  in  fifteen  minutes.  Under  moist  compresses,  with  dry 
covering,  around  the  chest  or  abdomen,  the  cutaneous  temperature 
rose  in  some  cases  even  after  two  and  one-half  hours  had  expired. 
The  temperature  of  the  skin  fell  if  the  wet  compress  was  not  protected 
by  a  dry  one,  doubtless  owing  to  evaporation.  The  temperature  be- 
tween the  skin  and  the  compress  continued  higher  than  that  of  the 
skin,  for  an  hour  or  longer,  and  fell  when  the  compress  began  to 
dry.  Covering  the  wet  linen  compress  with  some  waterproof  material 
prevented  drying  of  the  compress,  owing  to  the  obstruction  of  evapora- 
tion; the  cutaneous  temperature  did  not  fall.  The  highest  tempera- 
tures were  obtained  under  dry  compresses  of  linen  and  flannel,  either 
covered  with  some  impervious  material  or  left  uncovered.  This  ob- 
servation would  confirm  the  value  of  the  old-fashioned  cotton  and  oil- 
silk  jacket  for  revulsive  purposes. 

*Cent,ralblatt  fur  die  medicinischen  Wissenschaften,  1882,  No.  13. 
+  "  I'athologie  und  Therapie  der  Phthise,"  1887. 


156        THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

The  ideas  entertained  hitherto  on  the  subject  of  cold  and  warm 
compresses  are  so  vague  that  their  mode  of  action,  as  ascertained  by 
actual  experiments,  is  of  value.  It  is  evident  from  these  observations 
that  there  is  no  special  advantage  in  applying  hot  compresses  for  re- 
vulsive purposes,  because  it  is  difficult  to  maintain  their  temperature. 
Such  a  compress,  especially  if  covered  with  oiled  silk  to  prevent  neces- 
sity for  frequent  renewal,  is  chiefly  useful  for  purposes  of  influencing 
local  inflammatory  processes  by  increasing  leucocytosis,  and  thus  bring- 
ing about  suppuration  when  the  latter  is  unavoidable  or  desirable. 
This  observation  confirms  the  value  of  the  old-fashioned  poultice,  cov- 
ered with  oiled  silk,  which  every  practical  physician  has  applied  with 
satisfaction. 

On  the  other  hand,  whenever  revulsive  action  with  a  continuous 
tonic  effect  is  desired,  the  cold  wet  compress,  covered  with  dry  flannel, 
is  superior  to  all  other  applications,  because  it  raises  the  cutaneous 
temperature  in  a  physiological  manner — by  reaction — to  a  point  beyond 
the  normal,  and  on  each  renewal  causes  a  dilatation  which  results  in 
an  afflux  of  blood  into  the  part.  Such  compresses  should  not  be  renewed 
too  often,  however;  the  best  rule  being  to  renew  them  just  before  they 
become  dry.  If  the  patient  complains  of  chilliness  of  the  part,  this  is 
an  evidence  of  feeble  reaction,  which  may  be  counteracted  by  removing 
the  compress  and  applying  colder  water  with  friction  to  the  part  for  a 
very  brief  period,  or  by  simply  reducing  the  temperature  of  the  com- 
press. Here,  as  in  all  other  hydriatric  procedures,  the  fact  is  evident 
that  the  colder  the  water  within  reasonable  limits  and  the  warmer  the 
skin,  the  more  active  the  reaction  which  follows. 

Therapeutic  Indications. — In  tonsillitis  and  other  inflammatory  throat 
troubles  the  stimulating  compress  has  been  used  effectively ;  not,  how- 
ever, as  is  ordinarily  supposed,  for  the  purpose  of  cooling  the  tonsils, 
etc.,  but  with  a  view  to  producing  a  hypersemia  in  the  tissues  lying 
between  the  inflamed  part  and  the  compress,  and  chiefly  by  reflex 
action  to  render  the  affected  part  anaemic.  When  suppuration  is 
threatening  and  the  physician  desires  to  hasten  it,  the  throat  compress 
is  less  wrung  out  and  is  allowed  to  remain  longer,  in  order  to  hasten 
the  process  by  the  warmth  thus  produced  and  maintained  (see  Rationale 
and  Technique). 

The  chest  compress,  described  above,  is  not  used  by  the  author  for 
cooling  purposes;  for  reasons  referred  to,  he  does  not  approve  the 
application  of  ice  or  very  cold  compresses  for  haemoptysis  or  pulmonary 
hyperaemia.  The  stimulating  chest  compress,  however,  is  useful  in 
phthisis  and  pneumonia.  Aside  from  the  effects  referred  to  in  dis- 
cussing the  rationale  of  all  compresses,  the  chest  compress  causes  a 
deep  inspiration,  and  thus  aids  in  filling  the  lungs  with  oxygen  and  ex- 


THE   PRACTICE   OF   HYDROTHERAPY.  157 

pelling  accumulated  secretions.  Evaporation  from  the  heated  compress 
slowly  goes  on  through  the  badly  conducting  flannel  covering,  creating 
a  warmth  around  the  chest,  which  is  comforting  to  the  patient,  allays 
cough  and  dyspcena,  and  thus  contributes  materially  to  that  allevia- 
tion of  symptoms  which  leads  to  recovery.  In  phthisis  and  subacute 
pulmonary  affecitons,  and  in  chronic  infiltration,  the  chest  bandage 
may  be  worn  day  and  night;  in  most  cases  its  use  at  night  suffices. 

In  febrile  cases  nothing  contributes  more  to  the  reduction  of  tem- 
perature, relief  of  pain,  and  alleviation  of  the  general  malaise  than  dc 
the  chest  compresses,  containing  just  enough  water  not  to  permit  its 
flowing  upon  adjoining  parts.  Such  a  compress  may  be  renewed  as 
the  case  demands. 

In  pneumonia  the  chest  compress  is  the  most  important  remedial 
agent,  if  applied  every  half -hour  when  the  temperature  is  above 
102.5°,  hourly  if  below,  and  removed  when  it  falls  below  100°.  The 
cold  compress  (60°  F.)  produces  a  deep  inspiration;  it  contracts  the 
cutaneous  vessels,  which  rapidly  dilate  and  soon  form  a  soothing  poul- 
tice differing  from  the  old-fashioned  warm  poultice  in  being  more 
cleanly,  and  in  maintaining  a  tonic  dilatation  which  aids  the  heart  in 
propelling  the  blood  through  the  contraction  of  the  vascular  coats, 
which  warm  applications  would  paralyze  by  relaxation.  One  cause  of 
heart  failure  will  thus  be  removed  by  the  half -hourly  stimulus  to  the 
cutaneous  arterioles,  arising  from  the  shock  and  subsequent  reaction. 
That  temperature  is  also  reduced  by  the  wet  compress  in  pneumonia 
the  author  has  repeatedly  observed. 

In  phthisis  and  subacute  pulmonary  and  bronchial  affections,  the 
chest  compress,  applied  only  when  the  patient  is  in  bed,  produces  not 
only  a  stimulating  and  tonic  effect,  but  also  a  calming  influence  upon 
the  cough  and  softening  of  the  secretions  which  add  immensely  to  the 
patient's  comfort  without  the  detrimental  effects  of  opiates  and  expec- 
torants. The  process  of  equalization  of  temperature  between  the  skin 
and  compress  is  accompanied  by  the  formation  of  moist  vapor  which, 
being  prevented  from  escaping  through  the  non-conducting  flannel 
covering,  bathes  the  chest  and  probably  penetrates,  as  has  been  shown 
in  the  physiology  of  the  skin,  through  the  latter  and  influences  cell 
life  and  local  circulation.  The  positive  difference  between  the  old- 
fashioned  poultice  and  its  impermeable  covering  and  the  properly  ap- 
plied compress  with  its  flannel  covering  lies  in  the  fact  that  the  former 
lacks  the  refreshing  and  stimulating  effects  resulting  from,  reaction 
after  the  cold  procedure,  a  difference  which  must  inure  to  the  advan- 
tage or  disadvantage  of  feeble  circulatory  conditions. 

Whenever  the  chest  compress  is  to  be  discontinued,  as  Avhen  the  pa- 
tient rises  from  bed,  the  parts  beneath  it  should  be  well  rubbed  with  a 


158        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

cold  damp  cloth,  followed  by  hand  friction  and   warmer  clothing,  to 
maintain  the  local  and  general  stimulation. 

The  abdominal  compress  has  been  found  very  useful  in  many  acute 
diseases,  especially  in  typhoid  fever  as  recommended  by  Brand,  for  the 
purpose  of  continuing  the  reduction  of  temperature  following  the  full 
bath,  in  gastritis,  hepatitis,  peritonitis,  appendicitis,  and  in  the  entero- 
colitis  of  children  and  adults  when  accompanied  by  fever.  In  these 
cases  it  reduces  temperature,  and  by  producing  hyperaemic  conditions 
of  the  skin  (contrary  to  the  commonly  accepted  idea)  it  acts  as  a  revul- 
sive. Moreover,  the  soothing  effect  of  such  a  compress  is  an  invaluable 
therapeutic  auxiliary  in  these  trying  cases,  not  infrequently  preventing 
the  necessity  for  anodynes,  hypnotics,  and  antipyretics.  For  these 
purposes  frequent  renewal,  about  every  hour,  is  required.  The  author 
has  long  ceased  to  depend  upon  intense  cold  applications  (ice  bags) 
over  the  region  of  the  appendix  and  other  inflamed  parts,  for  aborting 
inflammatory  processes,  or  for  checking  internal  hemorrhrages  (hae- 
moptysis). As  a  local  anaesthetic  the  ice  bag  has  been  found  useful,  es- 
pecially in  appendicitis,  in  the  early  stage  of  which  opiates  should  be 
avoided  because  they  obscure  the  most  important  indications  for  surgi- 
cal interference. 

In  many  chronic  diseases  involving  the  intra- abdominal  organs,  be 
they  functional  or  organic,  a  properly  applied  Neptune  girdle  will  be 
found  of  great  value.  Here  the  wet  compress  should  be  worn  until  it 
is  nearly  dry.  In  the  various  chronic  gastro-intestinal  disturbances  of 
adults  and  children,  which  lie  at  the  foundation  of  dyspepsia,  diarrhoea, 
and  constipation,  such  a  compress  is  very  useful  if  worn  day  and  night. 

In  chronic  appendicitis,  occurring  in  two  colleagues,  Drs.  B.  and 
W.,  a  wet  compress  was  worn  continuously  over  the  right  iliac  region 
for  over  a  year,  with  the  result  that  there  has  been  no  recurrence  dur- 
ing the  past  ten  years.  I  am  in  the  habit  of  ordering  these  continuous 
wet  compresses  renewed  twice  or  three  times  daily  in  many  cases  of 
old  exudations  near  the  surface  of  the  body. 

In  insomnia  the  Neptune  girdle,  applied  at  bedtime,  has  served  me 
well  as  an  auxiliary  by  reason  of  its  derivative  and  soothing  effects. 

In  gastric  troubles,  especially  in  obstinate  vomiting,  the  Winternitz 
combined  compress  (page  147)  has  proved  of  good  service  after  failure  of 
all  other  measures.  The  first  case  in  which  Winternitz  applied  this 
measure  was  that  of  an  hysterical  woman,  who  was  dyspeptic,  had  lost 
appetite,  had  eructations,  cardialgia,  and  constant  vomiting,  which  had 
reduced  her  greatly.  Despite  all  treatment,  including  hydrotherapy 
and  rest  cure,  she  grew  worse.  Winternitz  applied  his  wet  compress 
covered  with  the  hot-water  coil  and  ordered  a  glass  of  milk  half  an  hour 
later.  Neither  pain  nor  vomiting  occurred.  The  application  was 


THE   PRACTICE   OF   HYDROTHEEAPY.  159 

repeated  each  time  before  nourishment  was  given.  The  latter  was 
gradually  increased  in  quality  and  quantity.  After  the  patient  left 
the  bed,  the  apparatus  was  applied  in  the  sitting-posture  with  the 
same  result.  Eapid  improvement  in  the  general  condition,  weight, 
and  haemoglobin  ensued  and  continued. 

In  cases  of  obstinate  vomiting  of  pregnancy  Buxbaum*  obtained  a 
good  result  in  one  week.  Wendringer  reports  in  the  same  journal  the 
successful  management  of  great  emaciation  with  diarrhoea  in  a  preg- 
nant woman,  by  the  use  of  a  high  hot  enema  followed  by  the  Wiuter- 
nitz  combination  compress. 

In  acute,  subacute,  and  chronic  rheumatism  the  wet  compress  is  an 
important  auxiliary  to  other  treatment.  In  the  J.  Hood  Wright  Me- 
morial Hospital  acute  articular  rheumatism  is  treated  with  greater 
satisfaction,  since  the  addition  of  these  compresses.  From  twenty 
to  thirty -five  per  cent  of  time  is  saved  by  the  abbreviation  of  the  attacks. 
The  duration  of  the  cases,  as  shown  by  a  comparison  instituted  by 
members  of  the  house  staff  with  those  of  other  hospitals,  is  certainly 
shortened.  In  these  cases  the  wet  compress  should  consist  of  two  or 
three  folds  of  old  linen,  tightly  covei'ed  with  flannel,  and  snugly  applied 
on  the  joints;  too  frequent  renewal  being  avoided  by  allowing  cold 
water  to  drip  upon  the  linen  after  exposing  it  anteriorly  by  removal  of 
the  flannel  cover.  Winternitz  recommends  wadding  as  a  superior  cover- 
ing for  the  compress  in  subacute  and  chronic  cases. 

The  hot  fomentation  compress  demands  a  separate  description.  It  con- 
sists of  two  pieces  of  old  blanket,  about  eighteen  inches  square,  which 
is  saturated  with  boiling  water,  and  thoroughly  wrung  out  by  means 
of  a  wringer.  The  latter  may  be  constructed  of  a  crash  towel,  to  the 
upper  and  lower  extremities  of  which  strong  sticks,  about  twenty -five  or 
thirty  inches  long,  are  secured  by  stitching,  so  that  their  ends  project  on 
each  side.  This  wringer  is  placed  in  a  basin  and  the  blanket  pieces 
are  laid  upon  it.  Boiling  water  is  now  poured  upon  the  latter  until 
they  are  thoroughly  saturated.  The  sticks  are  used  for  twisting  the 
towel  in  opposite  directions,  so  that  not  a  drop  of  free  water  remains 
on  the  blanket  compress.  The  painful  parts  which  are  to  receive  the 
hot  fomentation  are  well  anointed  before  the  patient  is  snugly  wrapped 
in  a  dry  blanket  pack.  This  accomplished,  he  is  approached  by  the 
attendant,  holding  the  twisted  towel  containing  the  hot,  moist  blanket 
cloths.  These  are  laid  aside  until  he  has  opened  the  blanket  sufficiently 
to  slip  the  hot  fomentation  out  of  the  towel  upon  the  affected  part. 
This  being  rapidly  done,  the  enveloping  blanket  is  quickly  closed.  If 
the  patient  complains  of  the  heat,  he  should  be  persuaded  to  bear  it. 
The  fact  that  the  receiving  part  has  been  anointed  and  that  the  hot  water 
*  Blatter  fur  klinische  Hydrotherapie,  1892,  p.  56. 


160        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

has  been  expelled  from  the  cloth  precludes  any  danger  of  a  burn.  That 
imperfect  wringing,  however,  enhances  this  danger  has  been  observed 
by  the  author  and  should  be  constantly  impressed  upon  the  attendant. 
In  the  beginning  of  the  treatment  it  is  well  not  to  apply  the  compress 
too  hot,  in  order  to  inure  the  patient  to  higher  temperatures  gradually. 
The  compress  should  be  renewed  or  repeated  every  ten  or  fifteen  minutes ; 
three  or  four  usually  suffice  to  produce  a  vapor  bath.  After  the  ter- 
mination of  the  fomentation  the  patient  is  gradually  uncovered;  suc- 
cessive parts  are  rubbed  dry,  and  quickly  washed  off  with  water  at  75°, 
with  friction ;  he  is  then  again  dried  and  put  to  bed.  When  accessible 
a  jet  or  fan  douche  of  85°  may  be  applied  with  great  benefit.  In  do- 
mestic practice  an  affusion  from  a  basin  of  water  at  75°  or  lower,  while 
the  patient  stands  in  a  tub  of  warm  water,  is  a  useful  substitute,  if 
followed  by  thorough  friction. 

In  sciatica  there  is  no  home  treatment  approaching  this  simple  pro- 
cedure in  efficiency  when  followed  by  the  cold  douche. 

M.  L ,  aged  thirty-five  years,  a  salesman,  has  been  suffering  from  sci- 
atica of  the  left  leg  for  two  months,  having  run  the  gamut  of  all  the  usual  rem- 
edies, from  salicylic  acid  to  actual  cautery.  His  recovery  was  probably  pre- 
vented by  continuing  on  his  journey  until  he  reached  New  Orleans,  where  he 
again  sought  medical  advice.  On  his  return  to  New  York  he  was  put  to  bed,  a 
mercurial  purge  was  administered,  and  he  was  put  on  a  milk  and  farinaceous 
diet.  Once  a  day  these  hot  fomentations  were  applied  to  the  sciatic  region,  and 
when  he  was  perspiring  he  was  allowed  to  remain  in  the  pack,  covered  by  an 
extra  blanket,  for  from  one  to  three  hours.  He  was  then  rapidly  dried  and  sub- 
jected to  an  ablution  with  water  at  70°.  This  treatment  was  continued  for  two 
weeks,  during  which  time  he  was  induced  to  drink  abundantly  of  water.  The 
pain  subsided  after  the  second  treatment,  and  the  patient  made  a  complete  recov- 
ery in  three  weeks. 

Lumbago  and  intercostal  or  other  muscular  rheumatic  affections  are 
rapidly  relieved  by  the  hot  fomentations,  repeated  every  night.  In 
recent  cases  two  or  four  applications  suffice  to  restore  suppleness  to 
the  muscles  and  render  motion  painless. 

THE  PRECORDIAL  COMPRESS. 

The  method  of  applying  this  compress  is  as  follows :  The  precor- 
dial  region  is  covered  with  three  or  four  layers  of  thin  linen,  wrung 
out  of  water  at  40°.  Upon  this  is  laid  a  rubber  coil  through  which 
ice  water  is  made  to  flow  steadily  from  a  bucket  or  other  reservoir 
placed  two  feet  above  the  level  of  the  bed  (see  illustration,  page  147,  for 
apparatus).  When  a  rubber  coil  is  not  available  a  large  ice  bag  filled 
two-thirds  with  finely  crushed  ice  may  be  substituted.  A  flannel  band- 
age around  the  chest  holds  the  compress  and  cooling  apparatus  securely. 
It  is  a  very  common  practice  to  permit  an  ice-water  coil  or  ice  bag  to 
remain  in  situ  continuously  and  to  be  removed  only  when  the  ice  is 


THE   PRACTICE   OF   HYDEOTHERAPY.  161 

melted.  Any  one  who  will  examine  the  skin  under  such  a  long-con- 
tinued compress  or  coil  may  observe  its  cyanotic  hue  and  chilled  condi- 
tion. If  stimulation  is  desired  of  the  circulation  rendered  sluggish  by 
"inflammatory  processes,"  this  paretic  condition  of  the  cutaneous  and 
deeper  vessels  certainly  defeats  the  object ;  if  cooling  is  desired,  the 
deeper  structures  become  less  accessible  the  more  the  superficial  ves- 
sels are  constricted  and  paralyzed.  The  author  has  therefore  adopted 
the  practice  of  never  permitting  an  ice  coil  to  remain  longer  than  forty 
minutes,  and  always  to  allow  local  reaction  to  ensue,  requiring  about  an 
hour  before  reapplying  it.  As  in  all  cold  procedures  it  is  well  to  be- 
gin with  higher  temperatures.  This  is  readily  accomplished  when  the 
coil  is  used,  water  without  ice  being  used  at  first,  and  the  latter  being 
gradually  added.  When  the  ice  bag  is  used — and  this  is  far  more  fre- 
quent— an  analogous  effect  may  be  produced  by  wringing  the  compress 
out  of  water  at  100°  and  to  prevent  the  too  rapid  penetration  of  the 
cold  by  making  it  thicker,  say  six  to  ten  layers  of  linen.  One  or  more 
layers  may  be  removed  at  each  renewal  of  the  ice  bag. 

Hat  ion  alt>.— The  cooling  of  the  structures  lying  above  the  heart 
doubtless  exercises  a  reflex  stimulus  upon  the  cardiac  nerve  supply. 
The  cardiac  contractions  become  more  vigorous,  being  evidenced  by 
increase  of  arterial  tension  and  filling  of  the  radial  artery,  the  pulse 
becoming  more  full  and  slow. 

Julien  *  showed  by  some  experiments  on  animals  that  the  ice  bag 
applied  to  the  precordial  region  was  capable  of  raising  the  blood  press- 
ure from  120  mm.  to  170  and  even  to  190  mm.,  at  the  same  time 
diminishing  pulse  frequency  considerably. 

Therapeutic  Indications. — In  cases  of  functional  arrhythmia  or 
tachycardia,  in  enfeebled  heart  action  due  to  loss  of  compensation,  and 
in  some  cases  of  adynamia  in  acute  diseases  the  precordial  cooling  com- 
press has  proved  in  the  hands  of  the  author  an  excellent  heart  tonic. 

Winternitz  has  obtained  such  good  results  from  it  that  he  regards 
it  as  the  "hydriatic  digitalis."  In  my  estimation  it  is  far  superior  to 
digitalis  in  the  cardiac  neuroses.  It  is  not  applicable  in  degenerative 
conditions  of  the  heart.  Julien  f  had  occasion  to  test  the  efficacy  of 
precordial  ice  applications  in  a  case  of  typhoid  fever  of  grave  type^-a 
typical  picture  of  the  ataxo-adynamic  form  of  the  disease.  The  patient 
had  lost  consciousness  and  lay  on  the  bed  entirely  uncovered,  in 
a  tetanic  attitude  varied  only  by  certain  spasms  of  the  head.  The 
temperature  remained  all  the  time  above  104° ;  the  pulse  had  reached 
successively  120,  140,  and  160.  Under  these  circumstances  Julien 
ordered  the  application  of  ice  over  the  heart  as  a  last  resort.  He 
watched  the  pulse  closely,  ready  to  stop  the  attempt  at  the  first  signal 
of  danger.  But  in  less  than  fifteen  minutes  he  saw  the  number  of  the 

*  Gazzetta  delle  Cliniche,  1887.  f  Loe.  cit. 

11 


THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

pulsations  diminish  and  their  amplitude  increase;  in  a  short  time  the 
almost  imperceptible  undulations  of  the  artery  gave  place  to  more  de- 
cided elevations.  Whenever  he  removed  the  refrigerant,  the  alarm- 
ing symptoms  returned  immediately,  so  that  after  many  trials  he  con- 
cluded to  leave  the  ice  bag  in  place  for  several  days.  After  that  the 
temperature  yielded,  the  cerebral  phenomena  disappeared,  and  the 
patient  was  out  of  danger.  He  is  convinced  that  she  owed  her  safety 
to  the  decisive  measure  which  he  had  adopted.  In  another  case  also 
he  accomplished  by  this  means  a  result  equally  remarkable.  In  con- 
clusion, he  remarks  that  the  beneficial  effects  show  themselves  in  from 
fifteen  to  twenty  minutes  from  the  beginning  of  the  application,  and 
reach  their  maximum  at  the  end  of  an  hour.  It  is  true,  he  says,  that 
they  are  very  evanescent,  disappearing  rapidly  when  the  application  is 
suspended,  but  there  is  no  danger  in  prolonging  it  as  long  as  the  gen- 
eral condition  remains  precarious.  In  some  cases,  under  its  action, 
the  height  of  the  pulsations  has  been  observed  to  be  tripled,  which 
means  a  pulse  more  ample,  fuller,  and  more  tense,  with  the  subsidence 
of  dicrotism,  intermittence,  and  irregularity,  and  with  a  longer  duration 
of  the  diastole.  An  interesting  fact  noted  is  that  the  effects  of  alcohol 
and  atropine  on  the  circulation  are  in  a  measure  neutralized  by  the 
ice  bag.  This,  says  the  author,  is  not  astonishing,  since  alcohol  has 
the  property  of  lowering  the  blood  pressure  by  paralyzing  the  vaso- 
motor  nerves,  and  atropine  increases  the  frequency  of  the  pulse  by 
paralyzing  the  pneumogastric  nerve.  This  antagonism,  he  suggests, 
may  possibly  be  serviceable  in  some  cases  of  poisoning. 

In  my  hospital  practice  this  observation  has  been  confirmed ;  not  in- 
frequently patients  have  been  tided  over  serious  adynamic  conditions 
by  the  precordial  cooling  compress. 

In  acute  endo-  and  pericarditis  the  precordial  compress  is  often  of 
great  value.  Its  effect  upon  cardiac  action  being  a  prolongation  of  the 
diastole,  the  inflamed  structures  are  afforded  more  rest  and  reparative 
action  is  furthered  by  improved  circulation.  In  these  cases  the  com- 
mon error  is  committed  to  prolong  the  application,  under  the  false  idea 
that  a  direct  cooling  effect  is  exerted  upon  the  inflamed  tissues.  The 
slightest  reflection  would  demonstrate  that  the  thickness  of  the  skin, 
areolar  tissue,  and  fat,  the  ribs  and  intercostal  muscles  overlying  the 
heart,  and  the  active  circulation  of  warm  blood  through  them,  would 
destroy  the  cooling  effect  of  such  a  compress  or  at  least  render  it  so 
slight  as  to  be  of  no  actual  value,  unless  the  vitality  of  the  overlying 
structures  were  destroyed  and  their  conductivity  thus  enhanced,  a  re- 
sult no  physician  would  aim  for.  Clinical  observation  confirms  the 
view  that  the  effect  of  the  precordial  compress  is  reflex,  and  that  this 
effect  is  encouraged  by  occasional  removal  and  reapplication,  the  latter 


THE   PRACTICE   OF   HYDROTHERAPY.  163 

being  always  guided  by  the  condition,  rapidity,  and  tension  of  the 
pulse.  In  myocarditic  conditions  or  when  compensation  is  danger- 
ously imperfect,  the  precordial  compress  must  be  used  with  caution. 
When  the  cardiac  area  is  not  diminished  or  the  pulse  improved,  and 
there  is  evidence  of  incomplete  emptying  of  the  ventricle,  and  espe- 
cially if  dyspnoea  or  cyanosis  ensue-  shortly  after  its  application,  it  may 
be  presumed  that  the  heart  muscle  is  degenerated.  Hot  applications 
act  more 'favorably  under  these  circumstances. 

The  spinal  compress  consists  of  several  layers  of  linen  well  wrung 
out  of  water  at  40°,  secured  to  the  nuclia  by  a  thin  cravat.  A  small 
rubber  coil  or  ice  bag  upon  which  the  neck  is  laid  furnishes  the  cooling 
effect  to  the  compress.  The  discomfort  of  such  a  procedure  forbids 
its  prolonged  use,  and  in  unconscious  patients  this  is  to  be  specially 
remembered.  The  reflex  effect  of  such  a  compress  upon  rapid,  feeble, 
or  arrhythmic  pulse  is  sometimes  astonishing.  For  a  few  moments 
the  pulse  becomes  more  rapid,  then  it  gradually  subsides  into  a  calm 
condition. 

In  chronic  endocarditis,  especially  in  aortic  insufficiency,  this  com- 
press has  assisted  me  materially  in  the  effort  to  restore  lost  compensa- 
tion, when  digitalis  acted  badly. 

Judgment  is  required  in  the  recognition  of  what  the  heart  is  capa- 
ble of  accomplishing,  and  in  the  selection  of  cases  accordingly.  When- 
ever the  pulse  improves  and  the  arteries  fill,  and  diuresis  increases, 
after  the  cold  coil,  the  latter  is  sure  to  be  useful. 

The  constant  coldness  of  hands  and  feet  is  sometimes  removed. 
The  most  favorable  cardiac  cases  for  the  cold  coil  are  those  in  which 
the  second  sounds  are  weaker  at  the  base  than  the  first  tone.  This 
condition  is  often  characteristic  of  Basedow's  disease.  Especially  if 
the  cautious,  intermittent  use  of  the  ice  coil  is  accompanied  by  a  milk 
or  vegetable  diet,  and  absolute  abstention  from  meat,  spices,  and  other 
irritating  foods,  improvement  is  obtained  quickly. 


CHAPTER   VII. 
THE  FULL  BATH. 

THIS  variety  of  bath  consists  o'f  the  complete  submersion  of  the 
body  in  water,  so  that  the  upper  surface  of  the  latter  reaches  the  lower 
part  of  the  chin,  the  head  being  the  only  part  uncovered  by  the  water. 
It  is  familiarly  known  as  the  tub  bath  in  this  country  and  as  "  Vollbad" 
in  Germany.  The  fact  that  this  is  the  chief  variety  of  bath  and  that 
the  technique,  effects,  and  therapeutic  application  differ  according  to 
the  temperature  of  the  water  used,  renders  it  necessary  for  the  more 
perfect  understanding  of  this  subject  to  divide  its  consideration  into : 

1.  The  cold  full  (friction)  bath. 

2.  The  warm  full  bath. 

3.  The  hammock  bath. 

1.  THE  COLD  FRICTION  BATH. 

The  author  has  termed  the  cold  full  bath  "friction  bath,"  to  dis- 
tinguish it  by  its  chief  elements,  low  temperature  and  friction,  and 
because  the  former  should  never  be  administered  without  the  latter,  as 
will  be  more  fully  shown. 

This  procedure  has  been  applied  with  notable  success  in  the  treat- 
ment of  typhoid  fever  and  other  infectious  diseases.  A  detailed  de- 


Fio.  39.— Steel-Clad  Portable  Tub. 

scription  of  the  method  and  rationale  demands  attention,  because  of 
the  frequent  and  almost  universal  resort  to  this  form  of  bath  in  modern 
practice. 

The  technique  of  this  bath  varies  with  the  therapeutic  object  we 
have  in  view,  as  will  be  shown.  The  cold  full  bath  is  applied  as  fol- 
lows :  In  acute  cases,  a  tub  of  sufficient  length  and  breadth  to  com- 
fortably accommodate  the  patient,  and  filled  to  three-fourths  of  its 


THE   FULL   BATH. 


165 


depth  with  water  ranging  from  90°  to  65°  F.,  as  required,  is  placed 
near  the  patient's  bed  and  protected  by  a  screen,  which  prevents  his 
being  excited  by  the  preparations. 

Unless  it  is  absolutely  unavoidable,  the  stationary  bathtub  in  the 
ordinary  city  bathroom  which  contains  a  watercloset  should  never 
be  used.  While  it  offers  certain  conveniences  for  obtaining  the  proper 
temperature  of  the  water,  it  is  inconvenient  to  the  nurses  and  oppres- 
sive to  the  patient  to  be  brought  into  the  contaminated  atmosphere  of 
so  small  a  room.  The  agitation  involved  in  transporting  the  patient 
even  from  an  adjoining  bedroom  may  also  be  injurious.  For  private 


FIG.  40.— Author's  Portable  Hospital  Tub. 

practice  the  ordinary  tin  bathtub,  between  five  and  six  feet  long, 
which  is  made  by  the  Central  Stamping  Company,  and  may  be  obtained 
at  the  tin  stores  and  at  the  large  city  department  stores,  is  perhaps  the 
best  adapted.  A  piece  of  carpet  being  spread  alongside  the  bed  the 
tub  is  placed  upon  it,  raised  upon  bricks  or  blocks  of  wood,  or  upon 
several  low  chairs  or  benches  to  nearly  a  level  with  the  edge  of  the 
bed.  The  head  of  the  tub  should  be  on  a  line  with  the  foot  of  the 
bed,  so  that  the  patient  may  be  turned  in  lifting.  This  position  will 
be  found  most  convenient  to  the  nurses,  who  have  to  remove  the  patient 
from  and  to  the  bed  and  rub  him  during  the  bath.  A  smaller  quantity 
of  water  will  be  required  if  the  head  of  the  tub  be  six  to  twelve  inches 
lower  than  the  foot.  When  water  must  be  conveyed  in  buckets  to  the 
tub,  this  position  will  facilitate  the  filling  of  the  latter.  The  tub  may 
be  partly  filled  before  being  placed  in  position;  then  water  may  be 
conveyed  to  it  in  buckets,  which  should  be  filled  and  emptied  with  the 
least  possible  noise.  A  convenient  mode  of  filling  the  tub  is  by  attach- 
ing a  piece  of  rubber  tube  to  a  washstand  faucet,  and  thus  leading  the 


166        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

water  into  it.  In  framed  country  houses  emptying  of  the  tub  may  be 
facilitated  by  attaching  a  rubber  tube  to  the  outlet  faucet  and  passing 
it  through  an  opening  in  the  wall.  The  author's  personal  observation 
warrants  this  statement.  In  hospital  practice  one  of  the  tubs  illus- 
trated in  Figs.  39  to  41  will  be  found  more  useful,  because  of  their 
superior  durability  and  the  ease  of  cleansing  them. 

Fig.  39  represents  a  steel-clad  portable  tub,  made  by  the  manufac- 
turers of  aseptic  surgical  furniture,  Richard  Kny  &  Co. 

Figs.  40  and  41  represent  a  portable  tub  designed  by  the  author 
for  use  in  the  small  wards  of  the  Manhattan  Hospital.  It  possesses 
certain  advantages  over  the  ordinary  six-foot  tub.  The  shape  of  the 
tub  is  well  shown  in  the  diagrams.  It  is  fifty  inches  long  and  twenty- 
seven  inches  wide,  and  consists  of  two  parts,  so  arranged  that  the 


Fm.  41.— Author's  Portable  Hospital  Tub.     Sectional  view,  showing  tube  leading  to  hot  water 

compartment,  B. 

patient's  lower  extremities  are  bent  at  right  angles  to  his  recumbent 
body,  the  feet  resting  upon  a  double  bottom,  which  is  filled  with  hot 
water.  The  latter  is  poured  into  the  double  bottom  through  a  tube 
with  a  funnel-shaped  opening  which  is  secured  in  one  corner  of  the 
tub ;  a  faucet  upon  the  posterior  aspect  of  this  hot-water  receptacle 
gives  exit  to  the  hot  water.  The  object  of  this  tub  is  to  afford  the  pa- 
tient an  easy  recumbent  position,  and  prevent  the  cold  water  from  chill- 
ing the  feet  and  producing  painful  cramps  during  the  bath  (Fig.  41). 
Its  short  and  compact  form  renders  it  more  portable  than  the  ordinary 
tub.  The  Kny-Sheerer  Company  has  constructed  the  bathtub  of 
highly  enamelled  wood  and  lined  it  with  tinned  copper,  thus  render- 
ing it  easily  cleaned.  The  height  of  the  tub  saves  much  back  strain 
to  the  nurses,  whose  constant  attention  is  required  for  friction  during 


THE   FULL   BATH. 


167 


continuance  of  the  bath.  A  similar  tub  has  been  in  constant  use  in 
the  hospital  for  fifteen  years,  and  has  proved  satisfactory  and  service- 
able. 

THE  BURR  PORTABLE  BATH. 

When  the  patient  or  his  friends  shrink  from  the  seemingly  heroic 
tub  bath,  or  when  the  latter  is  impracticable  on  account  of  lack  of 
room  or  for  other  reason,  the  tub  of  Dr.  A.  H.  Burr,  of  Chicago,  serves 
a  very  useful  purpose.  It  consists,  first,  of  a  large  rubber  sheet,  with 
rings  attached  near  its  margins  by  elastic  tapes;  second,  of  a  light 
vrooden  crib,  with  fastenings  along  the  lower  rail  to  hold  the  sheet. 


B. 

FIG.  42.— Burr  Portable  Bath.     A,  Frame  ;  B,  complete. 

This  frame  folds  by  two  movements  into  a  compact  bundle.  The  ac- 
cessories are  a  hose  with  metal  yoke  for  a  siphon,  a  sponge,  and  a  bath 
thermometer.  In  use,  the  rubber  sheet  is  first  slipped  under  the  pa- 
tient, brought  up  over  the  pillow,  and  tucked  up  alongside  the  body. 
The  frame  is  then  unfolded,  placed  down  over  the  patient,  resting  on 
the  mattress,  surrounding  patient,  pillow,  and  rubber  sheet.  The 
edges  of  the  sheet  are  then  drawn  up  over  the  top  rail  of  the  crib 
down  to  the  lower  rail,  and  fastened  by  its  rings.  This  completes  a 
light  and  perfect  tub,  capable  of  holding  twenty  gallons  of  water.  It 
can  be  emptied  by  siphon  in  four  minutes  (Fig.  42). 

A  Simple  Bed  Bath. — Dr.  A.  C.  Haven  has  devised  a  serviceable 
modification  of  the  Burr  bath,  which  reduces  its  cost  and  is  more 


168        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

simple.*  Such  a  bath  may  be  improvised  out  of  a  clothes  line,  a 
dozen  ordinary  wooden  clothespins,  and  three  yards  of  table  oilcloth. 
"  Tie  a  loop  of  rope  firmly  around  the  headboard,  another  around  the 
footboard,  and  connect  by  two  parallel  ropes ;  attach  the  oilcloth  with 
clothespins,  and  you  have  as  comfortable  a  bath  as  the  most  expensive, 
at  a  cost  not  exceeding  seventy-five  cents.  The  loops  around  the 
headboard  and  footboard  may  be  dispensed  with  in  metal  beds.  Four 
feet  of  garden  hose  with  a  wooden  plug  in  one  end  makes  an  excellent 
siphon.  Such  a  bath  I  have  now  in  use."  Dr.  Haven  says: 

"  My  only  desire  is  to  extend  the  benefits  of  the  bath  to  the  masses. 


FIG.  43.— Placing  Patient  into  Cold  Bath. 

The  patient  in  the  crowded  tenement  and  in  the  country  farmhouse 
can  be  shown  by  his  physician  in  a  moment  how  to  obtain  the  benefits 
of  that  health-giving  fluid — cold  water." 

Technique. — The  cold  friction  bath,  known  in  its  most  perfect  form 
as  the  Brand  bath,  is  administered  as  follows :  The  patient  receives  a 
stimulant  (alcoholic,  according  to  Brand;  four  ounces  hot  strong  coffee 
is  now  preferred  by  the  author).  He  is  undressed,  and  a  light  napkin 
is  applied  to  cover  the  sexual  organs.  His  face  is  now  bathed  with  ice 
water,  and,  if  too  feeble  to  step  into  the  bath,  he  is  lifted  into  it  by  two 
assistants  (Fig.  43).  The  tub  should  be  filled  with  water  at  a  tempeva- 
*  Medical  Record,  January  8th,  1898. 


THE   FULL   BATH. 


169 


hire  not  above  70°  F.  and  not  below  65°  F.  (I  have  obtained  these  temper- 
atures from  Brand  personally) ;  the  patient's  entire  trunk  and  extremity 
must  be  submerged.  A  useful  method  of  lifting  is  obtained  by  placing 
the  patient  on  a  cheap  strong  hammock,  from  which  the  sticks  have  been 
removed.  The  ends  are  firmly  twisted  avid  firmly  held  by  two  attendants, 
who  are  thus  enabled  to  lift  the  heaviest  patient  into  the  tub.  The 
hammock  is  allowed  to  remain  in  the  latter  until  the  bath  is  finished. 


.  44.—  Friction  in  Cold  Full  Bath. 


With  the  greatest  gentleness  and  least  fuss,  he  is  lowered  into  the 
water.  He  gasps  and  shudders  a  moment,  or  perhaps  cries  out. 
But  gentle  reassurance  by  word  and  deed,  a  calm  demeanor,  devoid 
of  haste,  and  the  absence  of  all  actual  force  or  argument  to  resist  his 
natural  desire  to  escape  from  the  seemingly  heroic  treatment,  rarely 
fail  to  quiet  his  apprehensions.  Friends  or  relatives  must  be  advised 
to  leave  the  room,  as  their  presence  would  increase  the  anxiety  of  the 
patient,  and  render  him  more  resisting  to  injudicious  and  unavailing 
explanations.  If  a  water  cushion  has  been  suspended  at  the  head  of 
the  tub,  it  will  afford  a  good  resting-place  for  the  patient's  head; 
a  large  water-cushion  ring  makes  a  comfortable  support  for  his  nates. 
In  the  absence  of  a  support  for  the  head  the  nurse  will  hold  it  up  with 
the  left  hand,  while  with  the  right  gentle  friction  or  chafing  will  be 
practised  over  successive  parts  of  the  body  (Fig.  44).  This  may  be  done 


170       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

perfectly  by  an  assistant,  who  in  private  practice  may  be  a  member  of 
the  family  or  a  friend.     Care  should  be  taken  that  every  part  of  the  body 
(except  the  lower  part  of  the  abdomen)  receives  the  benefit  of  these 
frictions,  which  are  regarded  as  of  supreme  importance  by  the  originator 
of  this  method,  in  preventing  chilling,  collapse,   cyanosis,  and  heart 
failure.     The  effect  of  this  continuous  gentle  chafing  is  a  suffused  red- 
ness, which  is  in  marked  contrast  to  the  previous  pallor  of  the  surface, 
and  demonstrates  that  the  calibre  of  the  superficial  vessels  is  being  con- 
siderably enlarged.     As  friction  is  executed  upon  successive  parts  of 
the  body,  we  really  manage  to  maintain  a  constant  contraction  and  dila- 
tation of  the  peripheral  vessels,  the  former  being  accomplished  by  the 
contact  with  the  cold  water  in  motion,  the  latter  by  the  friction  and  its 
attendant  reaction.      Complaints  of  chilliness  must  not  be  regarded  as  an 
indication  for  removal  of  the  patient  from  the  bath,  unless  it  be  accom- 
panied by  decided  chattering  of  the  teeth ;  the  former  is  voluntary  and 
may  be  emotional,  the  latter  is  usually  involuntary.     A  small  pulse,  a 
cyanotic  or  shrivelled  condition  of  the  hands,  too,  are  regarded  by  the 
inexperienced  as  a  warning  signal  to  remove  the  patient  from  the  bath, 
before  he  has  received  its  full  effect.     These  symptoms  may  be  due,  it 
should  be  remembered,  to  the  local  action  of  the  cold  upon  the  super- 
ficial vessels,  and  need  not  be  regarded  as  threatening  unless  the  face 
becomes  cyanotic.     Often  the  finger  nails  become  cyanotic  when  the 
patient  grasps  the  edge  of  the  tub  in  his  effort  to  hold  himself  while 
shivering.     Pressure  against  the  edge  of  the  tub  prevents  return  of 
venous  blood.     All  these  signs  may  therefore  be  fallacious.     Cyanosis 
of  the  face,  however,  is  a  manifestation  which  demands  cessation  of 
the  bath.     Not  being  submerged,  the  face  can  be  rendered  cyanotic 
only  by  actual  enfeeblement  of  the  heart  action,  a  condition  which  is 
exceedingly  rare  when  the  bath  is  administered  with  friction.     That 
a  small  pxilse  is  not  an  indication  of  heart  failure  will  be  evident  to 
the  reflecting  observer  from  the  fact  that  it  becomes  less  rapid  and 
compressible,  having  lost  its  dicrotic  character.     Bystanders  who  are 
not  familiar  with  these  seeming  manifestations  of  shock,  and  especially 
members  of  the  family,  should  be  excluded  from  the  room  during  and 
immediately  after  the  bath,  because  their  alarm  may  interfere  with  the 
proper  execution  and  duration  of  the  bath  and  thus  seriously  cripple 
the  efforts  of  physician  and  nurses.     If  their  presence  and  assistance 
be  needed,  a  simple  explanation  of  these  symptoms  should  be  given 
them  ere  they  occur,  so  that  they  may  be  forewarned  to  aid  the  atten- 
dants in  resisting  the  usual  entreaties  of  the  patient  to  be  removed 
from  the  bath.     The  duration  of  the  cold  full  bath  depends  upon  the 
object  in  view,  which  will  be  treated  under  the  proper  heads.     Several 
times  during  the  bath,  which  usually  lasts  fifteen  minutes,  a  basin  of  wa- 


THK   FULL   BATH.  171 

ter  at  50°  F.  is  gently  poured  over  the  patient's  head,  around  which 
a  handkerchief  folded  like  a  bandage,  two  inches  wide,  has  been  tied  in 
a  knot  over  the  nucha.  This  forms  a  gutter,  and  prevents  the  surprise 
produced  by  cold  water  flowing  over  the  face.  If  the  patient  is  somno- 
lent or  delirious,  cold  water  is  poured  over  head  and  shoulders  also. 

Before  the  termination  of  the  tub  bath,  the  patient' s  bed  should 
be  made  ready  in  the  following  manner :  A  double  blanket  is  spread 
upon  the  side  of  the  bed  to  be  occupied  by  the  patient  after  the  ter- 
mination of  the  bath ;  a  pillow  covered  by  a  towel  being  placed  under  its 
upper  portion.  Upon  the  blanket  is  spread  an  old  linen  sheet  (cotton 
is  inferior  because  it  does  not  absorb  water  readily,  and  it  is  sometimes 
necessary,  as  will  be  shown,  to  let  the  patient  remain  in  it  before  dry- 
ing). Several  hot-water  bags  or  bottles  are  prepared  for  the  feet, 
which  are  usually  cold  after  the  bath.  The  bath  being  finished,  one 
attendant  at  each  end  of  the  tub  lifts  him  upon  the  bed  or,  if  a  ham- 
mock is  used,  twists  it  into  a  convenient  form  for  holding.  The  ham- 
mock containing  the  patient  is  now  lifted  out  of  the  water,  held  a 
moment  aloft  to  allow  the  water  to  escape  from  it,  and  then  laid  upon 
a  cot  or  one  side  of  the  bed.  The  hammock  is  removed,  the  napkin 
covering  the  sexual  organs  is  rapidly  dropped,  and  he  is  placed  upon 
the  previously  prepared  blanket  and  linen  sheet,  so  that  the  upper 
edge  extends  above  his  shoulders  to  the  nucha.  He  is  now  carefully 
wrapped  as  follows: 

Being  laid  upon  the  sheet  so  that  his  nucha  touches  the  upper  edge, 
the  sheet  is  brought  around  the  body,  a  fold  being  pressed  in  between 
the  arms  and  the  body  and  between  the  lower  extremities,  with  the 
object  of  preventing  the  approximation  of  wet  body  surfaces.  The 
blanket  is  now  wrapped  around  the  patient  (Fig.  45).  If  the  temper- 
ature has  been  high,  above  103°  in  the  rectum,  the  patient  is  allowed 
to  lie  in  the  sheet  for  five  or  ten  minutes;  if  the  temperature  is  lower, 
he  should  be  at  once  dried  with  the  sheet  and  afterward  with  soft  towels. 
In  either  case  hot  bottles  may  be  placed  to  the  feet.  Usually  the 
patient  who  has  been  restless  previous  to  the  bath  will  fall  asleep.  In 
some  cases  shivering  may  continue  until  reaction  ensues.  Prolonged 
shivering  after  a  cold  bath  points  to  some  defect,  either  in  duration  or 
temperature.  The  former  must  be  diminished  or  the  latter  increased, 
or  both.  During  and  after  the  next  bath,  more  attention  should  also 
be  paid  to  friction  and  to  the  administration  of  stimulants  in  order  to 
further  reaction  by  vis  a  tergo.  The  application  of  heat  to  the  ex- 
tremities is  objectionable,  because  it  produces  an  artificial  heat  exter- 
nally, and  its  necessity  indicates  some  serious  defect  in  the  mode  of 
application  of  the  bath  if  it  recurs  after  several  baths. 

This  is  the  ideal  bath  designed  by  Ernest  Brand,  of  Stettin,  for 


172        THE   PRINCIPLES   AND   PRACTICE   OF   1IYDROTHKRAPY. 

the  treatment  of  typhoid  fever,  to  which  we  shall  have  occasion  to 
devote  much  attention.  The  technique  has  been  rather  minutely  de- 
scribed, because  the  author  has  seen  the  bath  so  frequently  applied  iclth- 
outf fiction  and  otherwise  improperly,  and  its  success  as  a  therapeutic 
measure  depends  upon  its  exact  execution.  In  a  discussion  of  "  tub- 
bing" in  typhoid  fever  by  the  New  York  Academy  of  Medicine,*  Dr. 
A.  B.  Ball  said  that  "  the  reason  why  the  doctors  at  Bellevue,  including 
himself,  had  given  up  the  bath  treatment  some  years  ago  was  that  they 
did  not  employ  rubbing;  everybody  who  had  tried  the  more  recent 


FIG.  45.— Wrapping  Patient  after  Bath. 

method,  adding  friction,  had  been  convinced  that  there  was  no  other 
method  at  command  which  was  so  valuable." 

Another  full  bath  which  has  received  much  well-deserved  praise 
from  clinical  observers  is  the  graduated  bath,  devised  by  Von  Ziemssen, 
of  Munich.  This  procedure  is  executed  as  follows :  The  preparation 
for  bathing  and  drying  the  patient  is  the  same  as  in  the  Brand  bath. 
Water  at  90°  to  86°  F.  is  poured  into  the  tub  until  it  is  about  one- 
third  full.  The  patient  being  placed  in  it,  the  attendant  bathes  the 
body  with  the  hand  and  sponge,  while  another  attendant  adds  water  at 
about  40°,  at  points  where  it  does  not  come  in  immediate  contact  with 
*New  York  Medical  Record,  November  7th,  1896,  p.  692. 


THK    FULL    HATH  173 

the  body,  until  the  temperature  of  the  water  reaches  77°  to  72°  F.  It 
will  be  necessary  usually  to  remove  some  of  the  water  from  the  tub  by 
a  faucet  or  pitcher  while  colder  water  is  added.  Chafing  is  here  also 
an  all- important  element  of  the  bath.  The  only  difference  between  this 
and  the  Brand  bath  is  the  gradual  accustoming  to  the  cold  water  in  the 
former,  which  seems  less  heroic  to  the  patient  and  his  friends.  The 
bath  may  be  prolonged  to  half  an  hour;  indeed,  this  is  the  time  re- 
quired for  it  by  Ziemssen.  AVhen  it  is  finished  the  patient  is  wrapped 
in  a  previously  warmed  woollen  blanket  without  being  dried,  for  a 
quarter  of  an  hour,  and  then  he  is  dried  and  his  clothing  is  replaced. 

The  Ziemssen  graduated  bath  is  less  objected  to  by  the  lay  people 
and  by  inexperienced  practitioners,  because  it  begins  with  tepid  water 
and  its  gradiial  reduction  is  less  intimidating.  There  are  several  ob- 
jections to  it,  however,  which  overbalance  this  sentimental  advantage. 
Its  long  duration  is  excessively  fatiguing  to  patients  and  attendants;  it 
requires  more  labor  to  supply  the  requisite  quantity  of  hot  and  cold 
water  and  ice.  The  addition  of  the  latter  is  especially  horrifying  and 
should  be  avoided  in  the  presence  of  the  patient.  Moreover,  it  is  an 
exceedingly  difficult  matter  to  reduce  water  from  90°  to  70°  F.  while 
the  patient  lies  in  it.  The  gradual  reduction  of  the  bath  temperature,  it 
may  also  be  stated  here,  diminishes  the  stimulating  effect  of  the  cold; 
a  point  which  is  more  fully  enlarged  upon  in  the  physiological  portions 
of  this  work  and  which  must  again  be  emphasized,  because  of  the  sin- 
gularly persistent  fallacious  idea  that  such  a  bath  is  less  heroic.  The 
patient,  being  exposed  to  a  more  prolonged  bath  and  being  less  stimu- 
lated, will  necessarily  react  with  less  promptness.  Hence  the  Ziems- 
sen bath  is  superior  to  the  Brand  bath  only  as  an  antithermic  proced- 
ure, when  the  latter  is  the  chief  indication,  which  is  rarely  the  case. 
Another  and  very  serious  objection  is  that  the  temperature  of  the  water 
for  each  subsequent  bath  must  be  raised  twenty-five  degrees  by  adding 
hot  and  removing  cold  water,  and  this  must  again  be  reduced  during 
the  bath.  This  is  an  increase  of  labor  and  trouble  without  adequate 
result.  The  Brand  bath  requires  little  if  any  changing  of  temperature ; 
the  same  water  may  be  used  for  twenty-four  hours  or  longer,  if  it  has 
not  been  soiled  by  the  patient.  The  temperature  of  the  water,  which 
may  rise  in  a  warm  room  during  the  interval  between  the  baths,  may 
be  restored  by  removing  a  few  bucketsful  and  replacing  them  with 
cold  water,  or  more  simply  by  wrapping  a  large  piece  of  ice  in  a  piece 
of  muslin  and  moving  it  to  and  fro  in  the  tub.  The  latter  should  be 
done  without  observation  by  the  patient,  who  may  be  terrified  by  see- 
ing ice  added. 

Physicians  and  others  who  have  been  subjected  to  both  varieties  of 
baths  claim  that  the  sudden  immersion  into  the  coldest  temperature 


174       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

required  is  far  less  unpleasant  and  chilling  than  the  gradually  reduced 
bath.  The  latter  is  certainly  far  more  fussy  and  troublesome. 

Rationale, — The  rationale  of  the  cold  full  bath,  which  has  been 
chiefly  applied  in  typhoid  and  other  infectious  fevers,  is  so  exactly  in 
accordance  with  modern  physiology  that  it  must  inspire  confidence, 
born  of  conviction  to  the  attendant  who  applies  it  with  a  clear  under- 
standing of  its  aims  and  capabilities. 

General  Effect. — The  cold  bath  produces  in  a  greatly  enhanced  de- 
gree all  those  effects  which  have  been  described  as  following  other  cold 
procedures.  There  are  a  simultaneous  contraction  of  all  the  cutaneous 
vessels,  a  simultaneous  shock  to  all  the  cutaneous  nerves,  a  shock — the 
results  of  which  would  be  dangerous  were  it  not  counteracted  by  active 
friction  of  the  body,  which  is  the  sine  qua  non  of  a  full  bath.  Be  it 
understood  here  that  I  regard  only  those  procedures  as  cold  baths  in 
which  the  body  is  submerged  completely  for  more  than  a  momentary 
period  in  a  tub  of  cold  water.  I  do  not  use  the  cold  bath  in  any  non- 
febrile  disease,  in  which  I  depend  upon  procedures  which  are  applied  to 
the  body  briefly  or  partially.  The  cold  bath  differs  in  its  rationale  from 
the  latter  procedures,  described  at  length  elsewhere,  in  that  it  produces 
its  effect  upon  the  entire  body  at  once.  The  reactive  capacity  of  the 
patient  is  strained  to  its  utmost  in  the  cold  bath,  while  in  ablutions  or 
douches,  the  application  being  local,  reaction  is  called  out  only  at  the 
points  of  impact  of  the  cold  water  and  is  aided  by  the  freedom  of  the 
remaining  portions  of  the  body  from  the  shock.  In  fevers  the  high 
temperature  present  aids  in  reaction  and  thus  neutralizes  the  effect  of 
the  shock,  especially  in  the  earlier  stages.  Inasmuch,  however,  as 
prolongation  of  the  shock  would  demand  more  reactive  capacity  than  a 
fever  patient  possesses,  friction  of  the  entire  body  is  resorted  to  in 
order  to  stimulate  the  cutaneous  nerves  and  vessels  artificially.  Eight 
well  is  this  accomplished,  both  in  reduction  of  temperature  and  stimu- 
lation of  the  nervous  system. 

Rationale  of  the  Action  of  Friction. — Winternitz  has  enunciated  the 
law  that  the  amount  of  temperature  reduction  from  a  hydriatric  pro- 
cedure depends  more  upon  the  intensity  of  the  thermic  and  mechanical 
irritation  of  the  cutaneous  sensory  nerves  than  upon  any  other  ele- 
ment. To  the  indefatigable  labors  of  Winternitz,  aided  by  his  assis- 
tants, we  owe  the  first  demonstration  that  active  mechanical  action  on 
the  skin,  combined  with  the  application  of  cold  water,  enhances  the 
temperature-reducing  effect  of  the  latter,  as  Pospischl  has  shown.  By 
friction  or  other  active  stimulation  of  the  surface,  circulation  during 
the  bath,  as  by  the  wet  sheet  and  half -bath,  etc.,  the  cutaneous  vessels 
may  be  made  to  fill  quickly  with  arterial  blood,  so  that  a  larger 
area  for  cooling  the  blood  which  circulates  in  near  proximity  to  the 


THE   FULL   BATH.  175 

cooling  medium — the  water — is  created.  The  cooler  blood,  passing 
inward,  is  exchanged  for  hot  blood  coming  from  within.  This  simple 
yet  effective  method  of  reducing  the  temperature  explains  many  incon- 
sistencies in  the  effect  of  cold  baths  in  fevers.  It  is  now  clear  that  the 
compensatory  heat  increase  which  follows  all  external  cold  applications 
does  not  depend  upon  the  absolute  amount  of  heat  abstraction  produced 
by  contact  with  cold  water,  but  upon  the  intensity  of  the  thermic -nerve 
irritation,  and  upon  the  degree  of  actual  cooling  of  the  peripheral 
terminal  nerve  fibres  which  govern  by  reflex  action  the  temperature 
regulation.  This  will  explain  why  two  cold  baths  of  the  same  temper- 
ature and  duration  may  produce  quite  different  effects  in  the  same  in- 
dividual, if  in  the  one  case  he  lie  quiet  and  undisturbed,  and  in  the 
other  he  be  subjected  to  active  friction  of  the  cutaneous  surface.  In 
the  first  instance  the  peripheral  circulation  is  impeded,  the  surface  is 
cooled  down  almost  to  the  temperature  of  the  surrounding  water,  the 
heat  production  in  the  muscular  layers  is  greatly  enhanced,  and 
the  rectal  temperature  not  much  if  at  all  diminished ;  in  the  other,  the 
peripheral  circulation  continues  stimulated,  the  area  of  the  vessels  is 
widened,  the  cutaneous  surface  is  cooled  down  less,  but  the  blood  com- 
ing to  its  superficial  vessels  is  cooled  more. 

Moreover,  the  elimination  of  moisture  from  the  skin  is  enhanced  by 
friction.  Weyrich's  and  the  more  recent  experiments  of  Ignatowski* 
show  clearly  that  the  vaporization  of  moisture  arising  from  a  good 
reaction  after  a  cold  bath  is  enormously  increased  for  a  considerable 
period,  while  it  is  reduced  by  the  cold  bath  without  reaction ;  since  the 
latter  is  the  chief  aim  of  the  cold  bath,  friction  becomes  its  most  im- 
portant element. 

Tremor  is  also  prevented  by  friction.  Changes  in  heat  production  are 
enhanced  by  the  tonic  or  clonic  muscular  contractions,  either  voluntary 
or  involuntary,  which  usually  occur  when  the  body  comes  in  contact 
with  water  much  below  its  own  temperature.  By  neutralizing  this 
effect — by  the  abolition  of  tremor — friction,  during  a  cold  bath  adds, 
therefore,  materially  to  its  antithermic  effect.  Although  tremor  may 
not  prevent  the  lowering  of  temperature  very  much,  it  is  one  of  the 
compensatory  elements  in  producing  heat  while  the  latter  is  being  lost 
elsewhere,  and  thus  aids  the  skin  in  its  compensatory  function  for  heat 
regulation. 

The  regulation  of  the  body  temperature  depends  mainly  upon  the 
changes  in  heat  dissipation,  therefore  chiefly  upon  the  condition  of  the 
peripheral  nerves  and  vessels;  inasmuch  as  we  may  influence  these 
energetically  by  the  cold  bath,  we  possess  in  it  a  powerful  agent  for 
affecting  the  temperature  of  the  body  in  disease. 

*   *  Loc.  cit. 


176        THE   PRINCIPLES   AND   PRACTICE   OF    HYDRO-THERAPY. 

Winternitz  points  with  justifiable  pride  to  the  confirmation,  by  the 
most  recent  investigations,  of  the  views  he  has  long  promulgated,  and 
he  concludes  his  magnificent  chapter* on  this  subject  as  follows:  "If 
you  connect  the  above  with  what  happens  in  thermic  and  mechani- 
cal procedures  with  regard  to  the  blood  and  heat  distribution,  the  con- 
trol of  heat  dissipation — or  rather,  as  I  may  say  now,  the  control  of  the 
degree  of  heat  production — you  will  find  it  quite  natural  that  hydro- 
therapy  is  the  most  sovereign  remedy,  not  only  in  the  first  stages  of 
febrile  diseases,  not  only  in  fevers,  depending  upon  heat  retention,  but 
in  all  fever  processes  especially,  because  no  other  remedy  is  so  capable 
of  meeting  the  chief  therapeutic  indications  of  the  latter." 

That  I  am  fully  in  accord  with  Winternitz  on  this  point,  I  shall 
endeavor  to  demonstrate  in  the  chapter  on  hydriatric  management  of 
fevers. 

The  shock  to  the  nervous  system  by  the  impact  of  cold  water  upon 
the  entire  body  in  the  cold  full  bath  and  the  stimulus  invariably  fol- 
lowing such  shock  are  intense  and  would  overwhelm  the  fever  patient, 
if  they  were  not  judiciously  applied  and  carefully  apportioned  to  the 
actual  condition  of  his  nerve  centres.  Usually  an  alcoholic  stimulant 
or  a  cup  of  strong  hot  coffee  is  administered  just  before  the  patient 
enters  the  bath,  and  the  constant  friction,  causing  a  wavy  impact  over 
some  parts  of  the  body  and  a  stimulus  to  the  nerve  terminals  at  other 
parts,  counteracts  the  shock  and  holds  it  not  only  within  safe  but  also 
within  effective  limits,  when  the  cold  bath  is  applied  in  fevers. 

Taking  typhoid  fever  as  the  most  representative  type  of  infectious 
fevers,  the  rationale  of  the  action  of  the  cold  bath  may  be  readily 
worked  out. 

There  is  an  infectious  process  established  in  the  organism  by  a  cause 
which  is  beyond  control  or  removal.  The  manifestations  of  the  pres- 
ence of  the  toxic  agent  are  as  follows : 

I.  The  nervous  system  receives  the  chief  brunt  of  the  attack  from 
the  specific   infective  agent.       Beginning  with   undefinable  malaise, 
ataxia,  general  lassitude,  somnolence,  other  adynamic  manifestations 
develop    which   culminate   in   stupor,    delirium   and  coma,  subsultus, 
tremor,  and  death. 

II.  The  temperature  is  invariably  elevated,  rendering  the  patient 
uncomfortable,   depriving  him  of  sleep,   impairing  his  organic  func- 
tions, and  if  the  elevation  is  prolonged  without  remission  sooner  or 
later  dangerous  interference  with  the  heart  and  brain  ensues. 

III.  The  circulation  is  seriously  interfered  with.     The  heart,  being 
called  upon  to  do  extra  duty,  threatens  to  fail  and  often  does  fail. 

IV.  The  skin,  kidneys,  and  lungs  are  so  seriously  handicapped  that 
they  fail  in  the  performance  of  their  important  functions. 

*Op.  cit. 


THE   FULL   BATH.  177 

V.  The  corpuscular  elements  and  the  chemical  composition  of  the 
blood  are  so  unfavorably  influenced  that  the  resistance  of  the  organism 
to  the  toxic  invasion  is  decidedly  impaired. 

I.  The  influence  of  the  cold  bath  upon  the  nervous  system  is  para- 
mount. Though  gradual  and  insidious  in  the  beginning,  the  manifes- 
tations arising  from  a  depreciation  of  the  nerve  centres  never  escape 
the  experienced  observer ;  indeed,  they  are  the  most  uniform  charac- 
teristics of  all  infectious  fevers.  Only  one  observation  will  be  quoted 
in  support  of  this  view.  Dr.  Edward  Delafield  says,  in  a  paper  on 
typhoid  fever,  read  before  the  New  York  Academy  of  Medicine,  *  in 
referring  to  the  reliability  of  symptoms  in  the  diagnosis:  "  A  study  of 
all  the  temperature  curves  shows  that  we  must  not  expect  too  close  a 
resemblance  to  the  schematic  curve."  In  contrast  with  the  unre- 
liability of  this  and  other  symptoms,  he  correctly  insists  that  the  ap- 
pearance of  the  patient  is  characteristic.  "  A  dull  apathetic  expression, 
the  skin  of  the  face  dusky  colored,  the  cheeks  often  bluish,  the  inind 
dull  and  sluggish,  all  these  conditions  were  well  marked ;  in  only  one 
case  were  they  notably  absent."  These  symptoms  are  the  expression 
of  a  depreciated  condition  of  the  nerve  centres,  which  in  typhoid  and 
other  infectious  fevers  are  the  leading  point  of  attack  and  must  there- 
fore be  the  leading  point  of  defence.  From  this  nerve  depreciation 
arises  a  condition  of  the  circulation  which  by  its  interference  with  the 
various  organic  functions  often  leads  to  lethal  results.  Since  all  other* 
functions  which  depend  upon  the  integrity  of  the  nervous  system  are 
inhibited,  as  will  be  shown,  the  importance  of  a  remedial  agent  which 
is  capable  of  influencing  favorably  this  fountain-head  of  all  vitality 
becomes  evident.  That  there  is  no  medicinal  agent  possessing  this 
power  has  been  made  sadly  evident  by  the  futility  of  search  for  such 
an  agent  during  the  past  centuries  of  the  history  of  medicine.  The 
cold  bath  alone  is  capable  of  demonstrable  and  rapid  action  upon  the 
nervous  system.  Although  its  immediate  effect  is  not  enduring,  its 
judicious  application  is  harmless  and  may  therefore  be  repeated  with 
sufficient  frequency  to  maintain  the  beneficial  action. 

The  stimulation  of  the  nerve  centres  by  the  cold  bath  arouses  them 
from  their  lethargy  and  thus  protects  the  organs  from  the  paralyzing 
influence  of  the  toxaemia.  Such  an  effect  is  evident  after  each  bath ; 
the  greater  the  delirium  or  stupor,  the  more  evident  is  it.  Kepetition 
of  the  bath  gives  a  totally  different  aspect  to  the  case.  As  the  author 
said  in  a  discussion  of  the  subject  by  the  New  York  Academy  of  Medi- 
cine :  f  "  The  effect  of  these  cold  baths  upon  the  patient  overwhelmed 
by  typhoid  may  be  likened  to  the  effect  of  external  stimuli  applied  in 
opium  poisoning.  In  the  latter  the  patient's  vitality  is  maintained  by 
preserving  the  nerve  centres  alert  until  the  poison  can  be  eliminated. 

*  Medical  Record,  November  12th,  1883. 
t  Medical  Record,  Febniary,  1890. 
12 


178        THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

This  requires  but  a  brief  time,  and  the  stimulating  treatment  may 
be  heroic  (flagellation,  faradic  electricity,  walking,  etc.),  while  in 
typhoid  fever  several  weeks  must  elapse  ere  the  bacterial  life  period 
terminates ;  hence  the  cold  bath  has  proven  its  value ;  the  systematic 
repetition  of  stimulation  of  the  cutaneous  nerve  conveys  it  to  the  cen- 
tral nervous  system,  and  maintains  its  integrity." 

Without  entering  upon  a  discussion  of  the  dissenting  views  of  reli- 
able laboratory  and  clinical  observers  on  the  specific  elements  of  this 
disturbance  of  the  heat  regulation,  i.e.,  whether  heat  production  or 
heat  retention  or  both  are  involved,  the  clinician  feels  called  upon  to 
meet  this  most  prominent  manifestation.  Unhappily  elevation  of  tem- 
perature had  so  long  been  regarded  as  the  most  important  element  of 
fever  that  it  was  difficult  to  convince  the  average  practitioner  that  it 
really  is  but  one  of  many  manifestations,  and  certainly  not  nearly  so 
important  a  one  as  the  disturbance  of  the  heart  and  blood-vessels  and 
of  the  eliminative  and  constructive  organs  of  the  body.  One  of  the 
advances  in  the  therapy  of  fevers  is  the  abandonment  of  the  lethal 
idea  of  high  temperature.  The  latter  renders  the  patient  exceedingly 
uncomfortable,  often  prevents  recuperative  sleep,  is  accompanied  by 
thirst,  drying  up  of  the  secretions,  jactitation,  and  other  manifesta- 
tions. It  becomes  therefore  a  prominent  indication  to  remove  it  or  at 
least  diminish  it  to  a  point  of  tolerance  by  the  system. 

From  the  earliest  time  the  cold  bath  has  repeatedly  been  applied 
for  this  purpose  with  more  or  less  success.  So  long  as  the  reduction 
of  high  temperature  by  the  cold  bath  was  regarded  as  a  simple  cooling 
of  the  superheated  blood  by  direct  contact  of  the  skin  containing  it, 
therapeutic  results  were  unsatisfactory.  Currie  and  more  recently 
Winternitz  and  others  have  demonstrated  that  the  mechanical  excita- 
tion of  the  skin  during  a  cold  bath  enhances  the  antithermic  action  of 
the  latter. 

This  fact  emphasizes  the  importance  of  precise  attention  to  the 
method  of  bathing.  To  immerse  the  patient  in  a  full  bath  of  low 
temperature  without  friction,  or  to  wrap  him  in  ice  sheets,  as  has  been 
done  in  the  faulty  practice  of  some  hospitals,  must  result  in  narrowing 
the  superficial  vessels  and  keeping  them  closed.  If  such  treatment 
does  not  induce  collapse,  reaction  may  slowly  take  place,  and  the 
former  high  temperature  again  be  reached  or  exceeded.  If,  however, 
the  patient  is  carefully  placed  in  a  bath  of  65°  to  70°  F.,  and  constant 
and  unremitting  gentle  friction  is  practised  over  the  entire  body  (Brand), 
the  coats  of  the  superficial  vessels  are  stimulated,  reaction  from  the  first 
shock  ensues,  the  vessels  contract  and  dilate  actively,  as  the  ruddy 
condition  of  the  skin  which  has  been  subjected  to  friction  testifies. 

The  mechanical  irritation  not  only  removes  the  obstacle  to  heat 


THE   FULL   BATH.  179 

dissipation,  but,  as  Weyrich  and  Pospischl  and  more  recently  Igna- 
towski,  whose  interesting  observations  have  been  referred  to,  have 
proved  by  exact  experiments,  it  increases  the  elimination  of  water 
from  the  surface  from  sixty  to  ninety  per  cent.  Moreover,  the  cooled 
blood  is  sent  from  the  dilated  vessels  back  to  the  interior  of  the  body, 
and  thus  a  direct  cooling  effect  is  produced  besides,  as  shown  above. 

The  baths,  therefore,  when  combined  with  friction,  fulfil  both  in- 
dications for  removing  high  temperature,  while  medicinal  antipyretics 
fulfil  only  the  first — heat  dissipation. 

In  the  discussion  of  the  best  temperature-reducing  baths  known 
to  hydrotherapy,  this  subject  will,  I  trust,  be  so  clearly  brought  out 
that  it  will  demonstrate  the  error  that  the  colder  the  bath  the  greater 
is  the  reduction  of  the  temperature.  This  erroneous  idea  has  been  the 
cause  of  numerous  disputations  between  the  adherents  of  Liebermeister 
and  those  of  Winternitz.  Voit,  to  whom  we  owe  so  much  in  connec- 
tion with  the  study  of  the  physiology  of  heat  regulation,  has  demon- 
strated that  increased  tissue  metamorphosis,  amounting  to  as  much  as 
forty  per  cent,  does  follow  the  application  of  cold ;  but  that  no  rise  of 
temperature  can  be  produced  in  this  way  if  we  do  not  have  a  simul- 
taneous disturbance  of  that  greatest  heat-regulating  organ,  the  skin. 
If  a  patient  with  a  temperature  of  104°  F.  is  placed  in  a  bath  of  65° 
F.,  and  allowed  to  remain  there  until  he  shivers,  the  vessels  of  the 
skin  become  more  contracted  and  heat  elimination  is  really  prevented. 
The  tremor  will,  to  a  certain  extent,  add  to  the  increase  of  inner  tem- 
perature by  producing  heat,  as  shown  by  the  experiments,  elsewhere 
referred  to,  of  Speck  and  Loewy.  How  different  will  be  the  effect  of 
a  regular  Brand  bath  with  friction  must  be  seen  to  be  appreciated. 
As  previously  described,  the  cutaneous  vessels  are  dilated,  and  more 
cooled  blood  is  carried  to  the  interior  to  be  exchanged  for  hot  blood. 
On  the  other  hand,  if  a  nerve  or  heart  stimulus  be  the  chief  object 
of  the  bath,  a  brief  application  of  cold,  with  mechanical  force  to  the 
surface,  as  described  under  the  head  of  half-baths,  produces  a  reaction 
which  does  not,  unless  prolonged,  affect  temperature  so  decidedly 
(because  the  blood  has  not  been  exposed  to  the  heat-lowering  influence 
sufficiently  long),  but,  by  exciting  the  reflexes,  brings  the  blood  to  the 
surface,  deepens  the  respiration,  and  invigorates  heart  action,  as  shown 
above. 

The  cold  bath  cannot  vie  with  the  medicinal  antipyretics  in  its 
temperature-reducing  properties.  The  latter  are  far  more  powerful, 
but,  as  will  be  shown,  the  reduction  produced  is  at  the  expense  of 
more  important  life-saving  functions.  The  cold  bath,  moreover, 
diminishes  temperature  slowly  but  surely,  each  day  or  two  showing 
a  small  gain  for  the  patient.  Since  the  high  temperature  is  usually 
due  to  the  intensity  of  the  infection,  the  counteraction  of  the  latter  by 


180        THE   PRINCIPLES   AND   PRACTICE   OF    if YDROTHERAPY. 

the  cold  bath  is  of  far  greater  moment  in  the  final  result  than  the  mere 
two-hourly  fall  of  several  degrees  following  the  use  of  medicinal  anti- 
pyretics. While  the  latter  may  be  profitably  employed  in  small  doses 
for  the  production  of  comfortable  sleep,  the  cold  bath  is  the  most  re- 
liable and  safe  antithermic  agent,  since  it  does  not  interfere  with  other 
functions  and  fulfils  other  important  indications. 

III.  Heart  Failure  stands  as  a  dread  spectre  at  the  bedside  of  every 
patient  suffering  from  an  infectious  fever.  Liebermeister  has  well 
said  that  "  it  is  much  more  difficult  to  prevent  cardiac  than  cerebral 
paralysis."  This  enfeeblement  of  the  heart  arises  from  the  disturb- 
ance of  the  vasomotor  and  automatic  ganglionic  centres,  which  are  in 
close  relation  to  the  central  nervous  system,  by  reason  of  which  the 
heart  and  peripheral  vessels  lose  their  normal  tone.  As  Winternitz 
has  so  ably  shown,  we  have  here  an  imitation  of  Golz's  experiments 
on  frogs,  which  demonstrate  that  a  loss  of  tone  in  the  vessels  of  a  large 
area  of  the  circulation  and  a  diminution  of  the  tension  in  these  vessels 
enfeeble  notably  the  action  of  the  heart. 

Romberg*  has  recently  furnished  a  careful  analysis  of  the  real 
causes  of  so-called  heart  failure  in  fever  which  offers  confirmation 
of  this  view.  What  is  the  part  played  by  the  heart  and  vasomotors 
in  those  manifestations  of  infectious  disease  commonly  regarded  as 
heart  failure?  Romberg  claims  that  in  the  course  of  most  acute  in- 
fectious diseases  we  observe  disturbances  of  the  circulation  which 
clinically  manifest  themselves  as  diminished  tension  and  diminished 
filling  of  the  arteries,  and  which  are  commonly  referred  to  heart  en- 
feeblement. Undoubtedly,  however,  the  condition  and  conduct  of  the 
peripheral  vessels  are,  in  connection  with  those  of  the  heart,  of  decisive 
import.  In  order  to  decide  how  far  the  heart  and  how  far  the  vaso- 
motors are  concerned  in  the  production  of  heart  failure,  Romberg  has 
made  some  experiments.  When  the  descending  aorta  is  compressed 
above  the  diaphragm,  or  when  the  belly  of  an  animal  is  subjected  to  mas- 
sage, blood  pressure  rises,  because  the  flow  into  the  abdominal  aorta  is 
interfered  with,  and  the  heart,  being  more  readily  and  completely  filled, 
drives  a  larger  quantity  of  blood  into  the  aorta.  But  the  conditions  are 
quite  different  when  increase  of  blood  pressure  is  produced  by  strong 
irritation  of  the  skin  or  mucous  membranes.  In  this  case  it  is  the  con- 
sequence of  a  reflex  irritation  of  the  vasomotor  centre  in  the  medulla 
oblongata,  as  is  also  the  interrupted  respiration. 

Starting  from  these  facts  Romberg  infected  a  number  of  rabbits 
with  the  bacillus  pyocyaneus.  This  resulted  in  a  temporary  rise  of 
blood  pressure  which  was  followed  by  a  diminution  to  an  extraordi- 
narily low  degree.  But  even  in  these  conditions  pressure  on  the  aorta 
*  Berliner  klinisclio  Wochonsehrift,  Nos.  17  and  52,  1895. 


THE   FULL   BATH.  181 

and  massage  of  the  belly  produced  a  decided  rise  of  blood  pressure, 
while  irritation  of  the  sensory  nerves  and  suffocation  were  entirely 
without  effect.  The  same  results  were  reached  under  infection  of 
Fraenkel's  pneumococcus.  From  this  experiment  Eomberg  concluded 
that  these  infectious  processes  damaged  the  circulation  by  a  paralysis 
of  the  vasomotors  without  interfering  with  the  working-capacity  of 
the  heart. 

Paessler*  confirmed  the  results  of  Romberg' s  observations.  He 
went  further,  however,  in  establishing  the  fact  that  the  damage  by 
these  infections  was  due  chiefly  to  the  vasomotor  centre  in  the  oblon- 
gata,  while  the  peripheral  and  vascular  nerves  and  muscles,  as  well  as 
the  centres  of  Golz  in  the  spinal  cord,  retained  their  normal  functionat- 
ing capacity  until  death.  Paessler  f  made  some  experiments  on  a  large 
number  of  rabbits  infected  with  Loeffler  bacilli.  As  in  other  infections, 
the  damage  was  inflicted  almost  altogether  upon  the  vasomotors,  with- 
out effect  upon  the  cardiac  capacity.  The  fnal  lethal  effect  upon  the 
circulation  urns  here  also  chargeable  to  paralysis  of  the  vasomotors  and 
not  to  any  damage  to  the  heart.  That  the  peripheral  vascular  nerves 
and  muscles  remained  intact  was  proven  by  injections  with  barium 
chloride,  which  produced  a  decided  rise  of  pressure.  Paessler  con- 
cludes his  observations  by  affirming  the  necessity  of  search  for  reme- 
dies which  will  more  surely  and  harmlessly  stimulate  the  vaso- 
motors. 

Happily,  we  are  already  in  possession  of  such  a  remedy.  That 
the  chief  effect  of  the  cold  bath  upon  the  peripheral  circulation  in  in- 
fectious fevers  is  due  to  the  stimulating  influence  upon  the  vasomotor 
centre  is  very  probable,  though  it  cannot  be  asserted  positively ;  but 
that  the  cold  bath  combined  with  friction  approximately  restores  by 
contraction  and  subsequent  filling  of  the  cutaneous  vessels  with  arterial 
blood  the  normal  tone  and  resistance  to  the  heart,  and  thus  reinstates 
lost  blood  pressure,  is  beyond  dispute.  That  this  effect,  combined 
with  the  reflex  stimulus  conveyed  to  the  nerve  centres  regulating  the 
heart  itself  by  the  cooled  blood  circulating  through  them,  refreshes  and 
invigorates  that  organ,  lessens  the  number  and  increases  the  force  of 
its  contractions,  and  prevents  dicrotism,  has  been  positively  demon- 
strated by  the  author  and  by  hundreds  of  other  observers. 

A  similar  refreshing  action  is  doubtless  exerted  upon  the  automatic 
ganglia  governing  the  heart. 

Dr.  Hobart  A.  Hare  demonstrates  this  by  the  apt  comparison  of 
the  heart  to  a  locomotive. J  "The  vasomotor  system  is  made  up," 

*Kongress  fur  innere  Medicin,  Wiesbaden,  April  7th,  1896. 

f  Kongress  Deutscher  Naturforscher  und  Aerzte,  Carlsbad,  September,  1902. 

\  Therapeutic  Gazette,  vol.  xii.,  No.  3. 


182        THE   PRINCIPLES   AND   PRACTICE   OF    HYDROTHERAPY. 

says  Hare,  "  on  the  one  hand  of  the  vasomotor  nervous  apparatus,  and 
on  the  other  of  the  blood-vessels  themselves.  The  resistance  offered 
to  the  heart  by  the  properly  acting  vasomotor  nervous  system,  through 
its  influence  on  the  peripheral  vessels,  is  identical  with  the  friction 
offered  to  the  driving-wheels  of  a  locomotive.  The  locomotive  is  in- 
tended to  meet  and  stand  any  resistance,  and  if  the  resistance  be  re- 
moved by  slippery  rails  the  wheels  fly  around  ineffectually,  racking 
the  machinery  and  destroying  its  usefulness. 

"  From  the  above  some  important  diagnostic  and  therapeutic  facts 
are  learned:  (1)  that  a  rapid  pulse  may  be  due  in  no  way  to  a  disor- 
dered heart,  but  to  vasomotor  relaxation;  (2)  that  the  proper  way 
to  treat  this  rapid  pulse  is  to  put  sand  on  the  track  and  increase  the 
resistance,  and  not  to  make  more  steam — or  give  digitalis — which  will 
only  cause  the  engine,  or  heart,  to  work  away  on  slippery  rails  with 
more  wear  and  tear,  and  make  no  progress." 

This  simile  is  intended  to  illustrate  the  clinical  fact  that  the  cold 
bath  increases  this  "resistance." 

In  order  that  the  tonic  effect  upon  the  heart  and  vessels  be  contin- 
uous, it  is  important  that  the  bath  be  repeated  at  sufficiently  frequent 
intervals  (three  hours  having  been  ascertained  as  the  proper  average) 
with  careful  regard  to  the  effect  produced.  It  would  be  impossible  as 
well  as  dangerous  to  maintain  the  failing  cardiac  action  by  alcoholic 
or  other  stimulants  during  a  period  of  many  days.  Repeated  cold 
baths,  with  accompanying  frictions,  not  only  aid  the  heart,  but  are 
free  from  deleterious  effects. 

In  the  early  stages  of  typhoid  fever,  when  reactive  power  has  not 
been  much  enfeebled,  chattering  of  teeth,  facial  pallor,  and  a  small 
pulse,  during  the  bath,  ensue  later  than  in  the  more  advanced  stages. 
But  these  must  not  deter  us  from  continuing  the  bath;  they  de- 
mand increased  friction  of  the  surface,  and  perhaps  a  little  stimu- 
lant. If  superficial  hyperaemia  is  readily  induced  by  the  friction,  a 
small  pulse,  or  even  a  pinched  countenance,  does  not  demand  removal 
from  the  bath.  These  may  arise  from  the  local  effect  of  the  cold. 
Decided  chilliness  and  prolonged  chattering  of  teeth,  however,  are 
indications  to  remove  the  patient,  because  the  muscular  contractions 
incident  thereto  induce,  as  Speck  and  Loewy  have  shown,  increased 
oxidation,  which  must  be  avoided  in  such  cases. 

The  most  positive  evidence  of  the  improved  condition  of  the  pulse 
after  the  cold  bath  is  found  in  the  fact  that,  while  it  feels  small  and 
almost  thread-like,  it  has  gained  in  force  and  tension,  and  continues  so. 
The  effect  of  the  cold  bath  is  not  so  pronounced  in  the  advanced  as 
in  the  early  stages  of  infectious  fevers.  This  may  be  explained  by 
the  fact  that  the  response  of  the  nervous  system  when  overwhelmed  by 


THE   FULL   BATH.  183 

toxaemia  is  more  feeble  and  therefore  the  reactive  power  is  more  in 
abeyance,  unless  baths  have  been  used  from  the  beginning.  In  the 
third  or  latter  part  of  the  second  week  of  typhoid,  either  a  higher  bath 
temperature  (75°  to  80°  F.)  or  more  brief  application  of  the  same  (65° 
to  70°)  is  indicated,  always  bearing  in  mind  that  the  rapid  application 
of  low  temperature  is  more  refreshing  and  stimulating,  though  not  more 
heat  reducing,  than  the  prolonged  application  of  a  bath  of  higher  tem- 
perature. The  reverse  idea,  though  erroneous,  seems  to  be  so  well 
established  in  the  lay  as  well  as  in  the  professional  mind  that  it  is 
difficult  to  dislodge  it. 

Modifications  required  in  other  infectious  fevers  may  be  devised 
under  a  careful  consideration  of  the  rationale  set  forth  above.  These 
will  be  referred  to  under  the  proper  headings. 

IV.  Failure  of  the  Eliminating  Organs — Skin,  Kidneys,  and  Lungs, 
(a)  The  skin  fails  in  its  function  of  depuratory  excretion,  as  evi- 
denced by  its  dryness,  pallor,  and  bloodlessness.  The  cold  friction 
bath  removes  the  pallor  by  bringing  more  blood  to  the  cutaneous 
vessels,  and  rendering  it  more  soft  and  pliant,  and  it  enhances  ex- 
cretion by  removing  dead  epithelium  which  obstructs  the  outlets  of 
the  sv,-eat  glands.  A  comparison  of  the  appearance  and  condition  of 
the  skin  before  and  after  a  properly  executed  friction  bath  demon- 
strates this  fact.  It  has  been  shown  that  the  elimination  of  toxins 
through  the  skin  is  promoted  by  certain  hydriatric  procedures. 

More  important,  however,  than  this  effect  is  that  produced  on  the 
kidneys. 

(b)  Failure  of  the  Kidneys. — The  interference  with  the  elimination 
of  toxic  products  from  the  kidneys  is  a  constant  manifestation  in  in- 
fectious fever.  That  the  quantity  of  urine  is  notably  diminished  is 
readily  observed,  but  that  its  chemical  constitution  is  changed  has  been 
recently  demonstrated  in  an  exact  manner.  Albert  Robin*  has  found 
as  the  mean  of  a  large  number  of  observations  that  the  accumulation 
of  waste  products  in  the  system  was  large  in  proportion  to  the  gravity 
of  the  case,  and  that  the  solid  constituents  of  the  urine  rose  from  48 
per  thousand  in  the  height  of  the  disease  to  60  per  thousand  during 
convalescence.  He  also  found  the  extractive  matters  in  the  normal 
blood  to  be  from  4  to  4.5  per  cent,  while  in  mild  cases  of  fever  they 
were  6.5  per  cent,  and  in  fatal  cases  reached  12.1  per  cent.  The 
blood  therefore  contained,  during  the  period  of  infection,  double  the 
normal  quantity  of  extractive  toxic  matter.  Robin  concludes  these 
interesting  observations  by  stating  that  in  infectious  poisoning  the 
organism  becomes  charged  with  insoluble  and  toxic  hydration  products, 
the  formation  of  which  is  accompanied  by  the  evolution  of  much  heat. 

*  Bulletin  tie  Therapie,  vol.  i.,  5,  1895. 


184        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

It  is  important  for  the  safety  of  the  organism  that  these  toxic  products 
be  eliminated  by  oxidation  and  changed  into  soluble  compounds. 

The  influence  of  cold  baths  upon  the  chemistry  of  the  respiration 
has  been  studied  by  Robin  and  Binet,  who  experimented  on  more  than 
one  hundred  cases,  which  furnished  one  thousand  analyses.  By  com- 
parison of  the  results  of  the  latter  with  those  obtained  from  the  analy- 
ses of  normal  urine,  an  important  number  of  facts  was  established 
which  may  serve  for  clinical  and  therapeutic  application.  In  the 
average  severe  cases  of  typhoid  the  relative  percentages  of  absorbed 
oxygen  and  of  exhaled  CO.^  are  decidedly  below  the  normal.  In  severe 
cases  which  result  in  recovery  the  relative  percentages  diminish  still 
more,  while  absorption  of  oxygen  through  the  tissues  increases ;  during 
convalescence  the  former  again  rises,  0  and  CO.,  are  decidedly  increased, 
the  largest  proportion  of  O  serves  for  the  formation  of  CO,,  and  the 
quantity  absorbed  by  the  tissues  does  not  differ  from  the  normal.  Even 
the  most  severe  and  fatal  cases  of  typhoid  demonstrated  an  inverse 
ratio  between  respiratory  changes  and  the  intensity  of  the  disease ;  the 
more  intense  the  latter  the  less  perfect  was  the  exchange  of  gases. 

These  facts  justify  the  application  of  remedies  which  increase  oxi- 
dation, while  those  not  so  influencing  the  latter  should  be  rejected. 
Antipyretics  undoubtedly  belong  to  the  latter  category,  because  their 
action  is  similar  to  that  of  the  disease,  and  the  fever  is  not  injurious 
to  the  organism,  but  rather  a  reaction  against  toxins.  Cold  baths,  on 
the  contrary,  augment  oxidation  and  reduce  temperature  by  enhanc- 
ing the  physiological  resistance  to  infection.  Baths  increase  combus- 
tion and  the  oxidation  of  the  extractive  products  of  disintegration  and 
hydration.  The  incapacity  of  the  living  cell  to  fix  and  retain  oxygen 
should  be  combated;  i.e.,  the  flooding  of  the  tissues  with  products  of 
decomposition  which  are  the  more  insoluble,  the  more  poisonous,  and 
the  less  easily  eliminated  the  less  oxygen  they  receive.  Cold  baths 
produce  these  marvellous  effects  in  typhoid,  because  they  enhance 
these  oxidation  processes,  heighten  arterial  tension,  enhance  cardiac 
capacity  and,  by  reason  thereof,  diuresis,  whereby  a  kind  of  inner 
purification  and  ready  removal  of  products  of  destructive  metamorpho- 
sis ensue.  Hence  the  success  of  cold  baths  agrees  with  the  above- 
mentioned  therapeutic  indications  to  favor  by  all  possible  means  the 
absorption  of  oxygen,  not  only  in  typhoid  fever,  but  in  all  infectious 
diseases,  especially  if  complicated  with  typhoid  conditions;  for  the 
oxidation  processes  are  the  protective  agency  of  the  organism.  Robin 
has  found  that  a  typhoid  patient  who  absorbed  for  each  kilogram  of 
weight  5  c.c.  of  oxygen  a  minute,  increased  the  amount  of  oxygen  taken 
up  to  6.49  c.c.  immediately  after  a  cold  bath.  The  COa  exhaled  in- 
creased from  3.77  c.c.  to  4.45  c.c.,  while  the  urea  increased  to  twenty 


THE   FULL   BATH.  1.S5 

per  cent.  Rubner  s  recent  experiments  *  confirm  the  findings  on  O 
intake  and  CO2  outgo  after  cold  baths. 

No  other  demonstration  could  so  clearly  prove  the  surpassing  value 
of  cold  baths  in  infectious  fevers. 

Roque  and  Weil  have  shown  by  reliable  experiments  f  that  in  the 
urine  of  typhoid-fever  patients  the  toxins  are  double  the  normal, 
while  under  the  bath  treatment  they  are  increased  fivefold  until  con- 
valescence occurs.  This  has  been  fully  corroborated  by  Hewetson  in 
the  Johns  Hopkins  Hospital  at  Baltimore. 

Not  alone,  however,  is  the  toxicity  of  the  urine  enhanced  by  cold 
baths,  but  the  quantity  secreted  is  enormously  increased.  It  is  not 
rare  to  note  the  passing  of  from  sixty  to  eighty  ounces  of  urine  during 
twenty-four  hours,  and  on  several  occasions  the  quantity  has  reached 
under  my  observation  over  one  hundred  and  twenty  ounces.  This  in- 
crease of  the  quantity  of  urine  is  an  almost  invariable  result  of  the  cold 
full  bath. 

V.  Influence  of  the  Cold  Bath  on  Corpuscular  and  Chemical  Con- 
stituents of  the  Blood. — It  has  been  shown  by  Boeckelmann  and  others 
that  there  is  a  rapid  diminution  of  the  blood  corpuscles  in  blood  taken 
from  the  cutaneous  vessels  in  infectious  diseases,  and  that  during  con- 
valescence this  is  equalized  and  restored.  Boeckelmann  does  not  claim 
that  there  is  an  actual  loss  of  corpuscles.  It  is  probable  that  by  reason 
of  the  enfeeblement  of  the  heart,  and  perhaps  of  the  paretic  condition 
and  loss  of  tone  in  the  cutaneous  vessels  (referred  to  above),  certain 
vessels  or  vascular  areas  are  deprived  of  the  normal  supply,  causing 
stasis  with  increase  of  blood  corpuscles — the  globular  stasis  of  Hiiter, 
which  yields  as  soon  as  the  normal  condition  of  the  heart  and  peripheral 
vessels  is  restored  during  convalescence.  That  this  stasis  may  be  read- 
ily removed  by  the  cold  friction  bath,  which  finally  increases  the  calibre 
of  the  cutaneous  vessels,  is  proved  by  the  observations  of  Cohnstein  and 
Zuntz,  who  demonstrated  that  the  quantity  of  formed  elements  in  the 
large  vessels  depends  upon  the  calibre  of  the  capillaries  and  upon  the 
activity  of  the  circulation  in  the  latter. 

The  effect  on  blood  corpuscles  and  haemoglobin  following  cold  baths 
in  typhoid  fever  has  been  carefully  studied. 

Breitenstein  J  offers  a  table  of  observations  made  on  twenty-six  pa- 
tients, which  demonstrates  that  in  the  large  majority  of  cases  the  cold 
bath  exercises  a  pronounced  influence  upon  the  blood  admixture.  In 
twenty-nine  cases  there  was  an  increase  of  at  least  fifty  thousand  red 
cells  to  each  cubic  millimetre,  which  was  accompanied  by  a  correspond- 

*  Loc.  cit. 
I      f  Wiener  klinische  Wochenschrif t,  1895,  No.  4. 

JArchiv  fur  ex perimentelle  Pathologic  und  Pharmakologie,  37,  p.  260. 


186        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

ing  increase  of  haemoglobin.  In  most  of  the  observations  the  increase 
reached  one  hundred  thousand  red  cells ;  in  one  case  it  reached  a  million. 
That  this  effect  of  the  cold  bath  upon  the  corpuscular  elements  of  the 
blood  is  not  due  to  the  reduction  of  temperature  is  evident  from  Brei- 
tenstein's  observations  as  to  the  effect  of  antipyrin,  which  reduced 
temperature  and  pulse,  without  increasing  the  red  cells. 

Breitenstein  concludes  from  his  carefully  conducted  experiments 
that  the  cold  bath  exercises  upon  the  circulatory  apparatus  an  influence 
which  changes  the  composition  of  the  blood  by  removing  stasis  in  cer- 
tain organs  or  internal  parts,  through  the  increased  energy  which  it 
induces  in  the  circulation,  and  that  the  deepening  of  the  respiration 
furthers  a  rapid  circulation,  which  counteracts  venous  stasis — effects 
which  cannot  be  obtained  from  medicinal  antipyretics. 

Thayer  and  Billings  of  Johns  Hopkins  Hospital  have  also  shown 
that  there  is  an  enormous  increase  of  the  corpuscular  elements  of  the 
blood  taken  from  the  lobe  of  the  ear  after  cold  baths  in  typhoid  fever. 
In  some  instances  the  leucocytes  were  enormously  increased  (threefold). 
This  observation  has  been  confirmed  by  many  investigators,  including 
my  son,  Dr.  H.  B.  Baruch,  at  the  Mount  Sinai  Hospital,  and  myself 
in  private  patients. 

Laboratory  investigations  tend  to  show  that  the  chief  defence  of  the 
organism  lies  in  the  blood,  probably  in  the  leucocytes,*  and  that  any 
method  capable  of  bringing  leucocytes  into  the  general  circulation  from 
the  remotest  portions  of  the  vascular  field,  where  they  have  been  slug- 
gishly dormant,  must  aid  the  organism  in  repelling  the  bacterial  enemy. 

Moreover,  Bouchard  has  shown  that  an  excess  of  acid  in  the  blood 
is  one  of  the  manifestations  of  auto-intoxication,  and  he  attempted  to 
neutralize  this  by  alkalies  without  avail.  Bireger  and  others  also 
proved  that  the  alkalescence  of  the  blood  is  diminished  in  infectious 
diseases.  Alois  Strasser  has  pointed  out  that  alkalescence  of  the  blood 
is  decidedly  increased  by  cold  hydriatric  procedures. 

It  follows,  therefore,  that  the  chemical  and  corpuscular  constitu- 
ents of  the  blood  which  are  unfavorably  influenced  by  the  infection  are 
restored  to  a  more  normal  condition  and  relation  by  cold  baths. 

*Emil  Fischl  fPrager  med.  Woch.,  vol.  xxii.,  5,  1897)  shows  that  by 
virtue  of  the  leucocytes  the  body  possesses  a  powerful  protective  agent  against 
the  invasion  of  pathogenic  organisms.  He  injected  the  Fraenkel  diplococcus 
into  the  aural  vein  of  rabbits;  a  decided  increase  of  the  white  corpuscles 
was  noted  in  the  animals  which  survived,  while  in  those  which  died  of  the 
infection  no  pronounced  leucocytosis  was  observed.  The  subsidence  of  the 
leucocytosis  was  synchronous  with  the  disappearance  of  the  micro-organisms 
from  the  blood. 


THE   FULL   BATH.  187 

The  quantity  of  haemoglobin,  according  to  Korowitzky,  *  fluctuates 
greatly  in  infectious  diseases,  especially  in  typhoid  fever  (18.48  to  7.24 
per  cent)  and  in  pneumonia  (16.74  to  8.64  per  cent).  This  change 
begins  in  the  first  stages  of  the  fever;  it  is  not  due  to  an  absolute  re- 
duction, but  to  the  partial  inanition  incident  to  these  diseases,  which 
decreases  not  only  the  mass  of  blood,  but  also  its  corpuscular  and 
haemoglobin  constituents. 

That  cold  hydriatric  procedures  favor  the  re -establishment  of 
normal  conditions  in  all  the  blood  constituents  has  been  amply  demon- 
strated. 

Conclusion. — The  detailed  rationale  furnished  above  shows  clearly 
that  the  cold  friction  bath,  properly  administered,  fulfils  every  thera- 
peutic indication  in  infectious  diseases  in  the  strictest  scientific  manner. 

THERAPEUTIC  INDICATIONS  OF  THE  COLD  FRICTION  BATH. 

Taking  the  view  that  a  cold  friction  bath  implies  the  immersion  of 
the  entire  body  in  cold  water  from  10°  to  30°  below  the  normal  body 
temperature  for  from  five  to  twenty  minutes,  with  continuous  friction, 
the  author  regards  it  as  indicated  chiefly  in  prolonged  fevers,  as  shown 
by  the  elaborate  discussion  of  its  rationale.  The  field  for  its  applica- 
tion is  therefore  enormous  despite  this  limitation. 

While  I  deem  the  cold  plunge,  i.e.,  dipping  the  body  in  water 
of  the  above-mentioned  temperatures,  as  useful  in  some  few  cases  of 
neurasthenia,  hysteria,  and  anaemia,  after  the  patient  has  been  trained 
by  milder  measures  to  bear  such  a  dip  with  a  good  reaction,  these 
diseases  do  not  come  under  the  therapeutic  indications  for  a  full  bath, 
because  the  patient's  stay  in  the  water  is  of  very  brief  duration  and 
friction  is  not  used  in  these  cases. 

Only  by  following  the  exact  technique  described  on  pages  153-154, 
may  a  cold  friction  bath  be  obtained.  Such  a  bath  is  useful  chiefly  in  the 
infectious  fevers,  each  one  of  which  demands  some  change  in  the  dura- 
tion of  the  bath  and  the  temperature  of  the  water,  as  will  be  shown  in 
the  detailed  description  of  the  methods  adapted  to  typhoid  fever, 
pneumonia,  the  exanthemata,  etc. 

FEVERS. 

The  general  practitioner  encounters  in  his  daily  routine  work  many 
cases  in  which  an  elevation  of  temperature  is  a  prominent  if  not  the 
principal  manifestation.  To  combat  this  symptom  appears  to  have 
been  the  chief  aim  of  the  therapy  of  the  past.  Upon  it  have  been  ex- 
pended more  thought  and  more  labor  than  upon  all  other  manifestations 

*  Congress  of  Russian  Physicians  in  Kiew,  1896. 


188       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

of  disease.  The  impress  of  this  long-existing  idea  is  still  recognized 
in  the  minds  of  the  lay  people,  and  unfortunately  it  has  not  been 
eradicated  entirely  from  the  minds  of  the  medical  profession.  There 
are  still  many  who  regard  elevation  of  temperature  as  the  most  peril- 
ous factor  of  acute  disease,  and  high  temperature  is  still  a  dread  enemy 
which  must  be  met  by  the  physician  with  powerful  weapons.  But 
this  fallacy  is  happily  losing  its  hold  upon  medical  men.  These  pages 
are  intended  to  aid  in  relegating  this  horrid  bugaboo  into  the  obscurity 
which  it  deserves,  and  to  emphasize  the  fact  that  depreciation  of  the 
nervous  system  and  its  resulting  inhibition  of  the  organic  functions 
and  later  degeneration  of  organs  are  the  chief  influences  which  menace 
life  in  fever,  and  to  neutralize  Avhich  every  therapeutic  energy  should 
be  summoned. 

Fevers  offer  the  most  prolific  field  for  hydrotherapeutic  success. 
If  we  dwell  upon  their  hydriatric  management  more  fully,  perhaps, 
than  upon  any  other  subject,  the  importance  arising  from  the  fre- 
quency, universality,  and  fatality  of  the  infectious  fevers  furnishes 
ample  warrant. 

Typhoid  Fever, — Taking  typhoid  fever  as  the  best  example  of  in- 
fectious fevers,  the  following  pages  will  be  devoted  to  its  treatment  by 
the  cold  friction  bath. 

The  frequent  discussion  of  typhoid  fever  by  our  medical  societies 
bears  evidence,  not  only  of  its  incalculable  importance,  but  also  of  the 
instability  of  our  present  therapeutic  methods  in  this  disease.  Brill- 
iantly and  learnedly  though  we  may  discuss  typhoid  fever,  favorable 
though  our  individual  statistics  may  be,  still  the  figures  of  our  boards 
of  health  reports  bid  us  "mend  our  ways"  in  language  more  eloquent 
than  human  tongxie  or  pen  can  formulate.  Twenty-five  or  forty  per 
cent  is  the  death  rate  from  typhoid  fever  in  our  American  cities; 
twenty-six  per  cent  is  the  mortality  of  the  New  York  hospitals  in  re- 
cent years,  according  to  Dr.  Delafield's  investigations.  The  import  of 
these  figures  cannot  be  overestimated.  May  they  be  changed?  This 
may  be  accomplished  by  the  cold  bath,  a  method  of  treatment  which 
has  the  sanction  of  long  usage,  the  authority  of  judicious  clinical  ob- 
servers, and  the  evidence  of  unimpeachable  statistics. 

It  is  proposed  to  offer  here,  not  empty  polemics,  but  arguments 
which  are  the  result  of  mature  deliberation  and  sifting  of  evidence 
afforded  by  clinical  and  experimental  data,  obtained  from  various 
sources  and  compared  with  my  own,  in  the  various  methods  of  treat- 
ment advocated  during  the  past  thirty  years  of  my  professional  career. 
After  twenty  years'  practice  in  a  large  field  I  had  settled  upon  the 
Ziemssen  graduated  cold-bath  treatment  as  the  most  promising  method 
of  treating  typhoid  fever,  and  I  obtained  more  satisfactory  results 


THE   FULL   BATH.  189 

from  it  than  from  any  other.  But  finding  many  objections  to  it, 
which  are  referred  to  elsewhere,  and  using  it  altogether  as  an  anti- 
thermic agent,  when  other  antipyretic  methods  came  into  vogue  with 
so  much  promise  of  success,  based  upon  the  idea  that  the  reduc- 
tion of  high  temperature  was  the  chief  desideratum,  it  was  natural  for 
me  to  be  carried  away  upon  the  tide  which  so  completely  swept  over 
the  entire  profession.  As  the  treatment  by  cold  baths  involved  so 
much  trouble,  and  proved  so  distressing  to  many  patients  and  their 
friends,  I  was  glad  to  abandon  it  in  favor  of  the  first  reliable  medicinal 
antipyretics  which  came  into  use  at  about  this  time.  The  physician 
who  was  in  active  practice  during  the  eighties  and  early  nineties  is 
familiar  with  the  potent  sway  exercised  at  that  time  by  the  antipyretic 
idea  in  the  therapy  of  fevers.  The  milder  forms  of  bathing  by  wet 
pack  and  sponging,  with  quinine,  antipyrin,  the  ice  coil,  and,  later, 
antifebrin  and  phenacetin,  gradually  displaced  the  expectant  plan,  just 
as  the  latter  had  displaced  the  previously  prevalent  spoliative  meth- 
ods and  the  irrational  (antithermic)  cold  bathing. 

A  review  of  experience  derived  from  personal  observation  in  private 
and  hospital  practice  and  in  that  of  many  colleagues,  as  well  as  from 
society  discussions,  develops  the  fact  that  the  mortality  of  typhoid  fe- 
ver iras  not  reduced  by  the  antipyretic  method  of  treatment.  A  fair,  con- 
scientious, and  exhaustive  review  of  the  results  of  the  various  methods 
in  vogue  during  the  past  thirty-five  years  has  demonstrated  that  the 
adoption  of  strict  cold  bathing  has  inaugurated  an  epoch  in  the 
treatment  of  typhoid  fever,  because  it  has  greatly  diminished  the 
mortality. 

How  fatal  typhoid  fever  is  at  the  present  time  may  be  gathered 
from  the  statistics  given  above.  This  mortality  is  even  larger  than 
that  furnished  by  the  recently  gathered,  careful  statistics  in  Germany, 
which  show  that  under  the  expectant  treatment  of  11,124  cases  the 
mortality  amounted  to  21.7  per  cent.  Dr.  Murchison  has  compiled 
27,051  cases,  in  which  the  mortality  per  cent  was  17.45. 

Jaccoud  has  collected  80,140  cases  on  the  continent,  with  a  mortal- 
ity of  19.23  per  cent.  The  English  army  statistics  averaged,  for  the 
six  years  ending  with  1877,  32  per  cent  mortality ;  in  the  navy  it  was 
25.5  per  cent. 

The  most  favorable  statistics  on  record  are  those  of  the  Boston 
City  Hospital,  furnished  by  Dr.  A.  L.  Mason.*  "With  the  exception 
of  eighty -nine  cases  treated  by  Dr.  Edes,  the  Brand  system  'has  not 
been  adopted  at  this  hospital,  but  pyrexial  symptoms  have  been  met 
by  cold  spo-iginy  and  affusions,  with  the  internal  administration  of 
antipyretics,  antiseptics,  and  tonics.  During  1890  and  1891,  six  hun- 
*  Boston  Medical  and  Surgical  Journal,  April  7th,  1893. 


190       THK   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

dred  and  seventy-six  cases  of  typhoid  fever  were  thus  treated,  of  which 
seventy  were  fatal  =  10.4  per  cent.  This  remarkable  result  is  doubt- 
less due  to  the  fact  that  over  one-third  of  the  cases  entered  during  the 
first  week  of  the  disease,  and  that  hydrotherapy  was  used  very  largely 
in  all  cases." 

These  statistics,  to  which  others  may  readily  be  added  were  they 
not  sufficiently  large,  present  to  us  the  appalling  fatality  of  typhoid 
fever  under  the  expectant  and  antipyretic  plans,  which  claim,  by  nour- 
ishing the  patient,  placing  him  in  good  hygienic  surroundings,  combat- 
ing complications  as  they  arise,  and  reducing  the  temperature,  to  con- 
duct him  to  a  safe  issue.  Much  stress  has  been  placed  during  the  past 
quarter  of  a  century  upon  high  temperature  as  the  predominating  ele- 
ment of  danger  in  typhoid  fever..  It  has  been  claimed  that  parenchy- 
matous  degeneration  of  the  heart,  kidneys,  and  other  organs  was  the 
direct  result  of  prolonged  high  temperature,  and  the  chief  energy  of 
therapeusis  was  expended  upon  this  hydraheaded  monster.  This  idea 
was  indeed  sustained  by,  if  it  did  not  originate  in,  the  marvellous  suc- 
cess of  the  cold- water  treatment,  which  Brand,  of  Stettin,  in  1861, 
brought  before  the  profession  in  Germany,  and  which  was  modified  by 
Liebermeister,  the  high-priest  at  the  altar  of  antipyresis,  as  well  as  by 
Jiirgensen,  Ziemssen,  and  others,  and  converted  into  an  antithermic 
bath. 

The  history  of  this  special  subject  is  instructive,  inasmuch  as  it 
illustrates  how  surely  bedside  experience  will,  sooner  or  later,  demolish 
the  most  stately  structures  erected  by  theoretical  reasoning.  Brand 
never  claimed  that  this  bath  treatment  was  chiefly  directed  against  the 
high  temperature.  On  the  contrary,  this  was  a  secondary  object  with 
him.  Liebermeister's  criticism  *  is  at  once  the  best  exposition  and  the 
highest  encomium  of  Brand's  method.  On  page  15  he  says:  "The 
work  of  Brand,  which  was  published  in  1861,  ranks  high  above  the 
level  of  the  publications  of  the  professional  hydropathists  of  to-day. 
Still,  the  author  occupies  pretty  much  the  ground  of  Priessnitz.  The 
pre-eminent  importance  of  abstraction  of  heat  is  not  sufficiently  recog- 
nized; the  main  action  of  water  is  more  than  that  of  stimulation,"  f  etc. 
Liebermeister  himself  has  changed  his  views,  as  is  evident  from  his 
more  recent  writings.  That  the  standpoint  of  Brand  is  correct,  and 
that  it  is  sustained  by  the  most  incontrovertible  evidence  of  experi- 
mental study,  seconded  by  clinical  experience  gathered  from  carefully 
recorded  data,  are  to-day  evident.  Thinking  men  now  realize  that  the 

*" Handbook  of  General  Therapeutics,"  Wm.  Wood  &  Co.,  1885. 

f  This  testimony  of  Liebermeister  relieves  Brand  of  the  charge  made  by 
Cursclimann  (Nothnagel's  Cyclopaedia),  that  the  baneful  influence  of  combating 
high  temperatures  in  typhoid  fever  arose  from  Brand. 


THE   FULL   BATH.  191 

introduction  of  the  powerful  antipyretics  has  not  reduced  the  mortal- 
ity of  typhoid  fever,  and  that  the  only  advantage  from  them  seems  to 
be  that  fo&  patient  is  enabled  to  die  with  a  nearly  normal  temperature. 
The  fact  that  the  statistics  of  private  and  hospital  practice  show  a 
mortality  reaching  beyond  twenty-four  per  cent,  since  the  introduction 
and  abundant  use  of  antipyrin  and  its  substitutes,  proves  their  inade- 
quacy. And  the  fact  becomes  more  glaring  when  statistics  of  the 
cold-water  treatment  reveal  the  astounding  reduction  of  mortality  to 
3.9  per  cent,  and  when  the  rationale  of  the  action  of  antipyretics  is 
carefully  studied. 

It  has  become  our  solemn  duty  to  pause,  weigh  the  reasons  of 
this  enormous  difference  in  the  mortality,  and  ascertain  if  it  may  not 
be  further  reduced  by  a  more  universal  adoption  of  the  Brand  bath. 
I  propose  to  establish  the  fact  that  this  mortality  may  be  reduced,  as 
Brand  has  reduced  it,  to  one  per  cent.  Those  who,  like  myself,  have 
personally  witnessed  the  fatality  of  typhoid  fever  in  New  York  City 
may,  as  I  once  did,  shrug  their  shoulders  in  doubt,  and  fortify  their 
argument  against  these  baths  by  their  own  small  statistics  gathered  in 
private  practice  and  not  recorded;  or  by  the  imperfect  records  of 
hospital  statistics,  in  which  persons  of  all  ages,  sexes,  and  conditions, 
and  cases  in  all  stages,  are  mingled  in  unutterable  confusion  and  ad- 
mitted usually  late  in  the  disease.  An  examination  of  the  following 
pages  and  an  analysis  of  the  reasons  offered  to  prove  the  superiority 
of  the  cold-bath  treatment  will  demonstrate  that  this  is  not  a  chimera, 
but  a  substantial  fact,  based  upon  the  most  reliable  clinical  data. 

Brand  offers  the  statistics  of  19,017  carefully  gathered  cases  of 
typhoid  fever,*  which  demonstrate  that  under  the  general  influence  of 
all  kinds  of  cold-bath  treatment,  without,  however,  its  strict  enforce- 
ment, the  mortality  has  been  reduced  from  21.8  per  cent  to  7.8  per 
cent.  But  this  is  not  all.  He  has  obtained  from  twenty-three  German 
and  French  distinctly  designated  sources  the  reports  of  5,573  cases  (to 
which  I  have  added  more  recent  reports),  statistical  evidence  which 
has  not  yet  been  and  cannot  be  controverted,  and  by  which  it  is 
clearly  shown  that  the  cold-bath  treatment  originally  recommended  by 
him  has  reduced  the  mortality  to  3.9  per  cent.  The  latter  percentage, 
however,  still  includes  many  imperfectly  managed  cases.  Eliminating 
these,  the  number  treated  strictly  by  Jiirgensen,  Vogl,  Brand,  and 
others  up  to  January,  1887,  amounted  to  1,223  cases,  of  which  twelve 
died,  a  mortality  of  one  per  cent.  And  yet  this  is  not  all,  for  the  most 
significant  fact  deducible  from  these  statistics  is  that  not  one  of  the 
twelve  deaths  occurred  in  any  case  that  came  under  treatment  before  the 
fifth  day.  Brand  boldly  asserts,  on  the  strength  of  these  1,223  cases,  of 
*  Deutsche  medicinische  "Wochenschrift,  1887. 


192        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

which  he  treated  one-fourth  in  private  practice,  the  remainder  coming 
from  Jiirgensen's  clinic  at  Tubingen  (which  approximates  private  prac- 
tice), Yogi's  military  practice  at  Munich,  and  the  military  hospitals 
at  Stralsund  and  Stettin,  that  all  cases  of  typhoid  fever  coming  under 
treatment  before  the  fifth  day  should  recover. 

Medical  statistics  are  proverbially  unreliable,  but  the  exactness  of 
the  figures  presented  by  Brand,  in  his  able  polemic  in  the  Deutsche 
medicinische  Wochenschrift  for  1887,  cannot  be  doubted  and  his  de- 
ductions cannot  be  gainsaid,  because  they  are  furnished  from  civil  and 
military  life,  from  university  clinics  and  military  hospitals,  in  which 
the  cases  were  observed  by  competent  and  well-trained  men,  and  they 
have  been  confirmed  by  more  recent  reports,  as  I  shall  show. 

Valuable  as  these  statistics  must  be  as  an  argument  in  favor  of  strict 
cold  bathing,  the  results  of  the  latter  are  better  illustrated  by  some 
comparative  statistics  made  by  several  clinical  observers.  For  in- 
stance, the  official  records  of  the  Second  Prussian  Army  Corps,  quoted 
by  Brand,  show  that,  while  from  1849  to  1866  the  mortality  among 
1,970  cases  was  26.3  per  cent,  it  was  reduced  among  2,714  cases  of 
strict  cold-bath  treatment  to  4.3  per  cent.  This  enormous  reduction, 
is  the  more  glaring  when  this  mortality  of  4.3  per  cent  is  compared  with 
that  of  other  armies.  In  the  French  army,  it  was  32.2  percent;  in 
the  Italian,  28.6  per  cent;  in  the  Austrian,  27.4  per  cent;  and  in  the 
English,  23.8  per  cent,  during  the  same  period.  Indeed,  so  striking 
was  the  reduction  of  mortality  wrought  by  this  treatment  in  the  Ger- 
man military  hospitals  that  the  Prussian  War  Department  deemed  it 
incumbent  upon  itself  to  issue,  on  January  25th,  1883,  a  circular  to  the 
medical  service,  in  which  it  was  urged  that  "  inasmuch  as  the  Brand 
treatment  has  been  instrumental  in  reducing  the  mortality  of  typhoid 
fever  in  the  various  hospitals  from  25  per  cent  to  8  per  cent,  we  are 
justified  in  expecting  that,  with  an  increased  perfection  and  more  gen- 
eral adoption  of  this  treatment,  it  may  become  possible  to  save  a  still 
larger  number  of  sick  men." 

As  doubt  has  often  been  cast  upon  the  correctness  of  these  statistical 
statements  and  their  applicability  to  our  own  country,  the  following 
opinions  from  reliable  sources  may  confirm  them. 

Dr.  J.  C.  Wilson,  of  Philadelphia,  now  Professor  of  Practice  in 
Jefferson  College,  wrote  me  on  October  16th,  1890 :  "  I  confess  to  having 
entertained  misgivings  as  to  the  accuracy  of  Brand's  statements  for  a 
long  time;  but  I  took  occasion  last  spring  to  investigate  the  matter 
systematically  for  myself.  No  one  who  has  done  this,  following  the 
method  closely,  and  avoiding  medication,  can  doubt  the  efficacy  of  the 
treatment.  In  this  community,  it  would  be  at  present  impracticable 
to  introduce  the  treatment  to  any  great  extent  in  private  practice ;  but 


THE   FULL   BATH.  193 

the  publication  of  statistics  which  are  incontrovertible,  aud  which  prove 
that  the  average  mortality  can  be  reduced  from  its  present  figures, 
perhaps  sixteen  per  cent,  including  hospital  and  private  practice,  to 
two  or  three  per  cent,  will  in  a  short  time  render  the  employment  of 
baths  practicable  both  in  public  and  private  practice.  I  find  the 
trouble  lies  chiefly  with  our  physicians,  some  of  whom  are  closely 
hidebound  and  subject  to  traditions.  But  there  are  many  others  who 
are  open  to  conviction." 

In  The  Medical  News,  December  6th,  1890,  Dr.  Wilson  says: 
"  Severe  symptoms  were  mitigated,  and  mild  cases  ran  a  most  favor- 
able course.  As  a  rule,  patients  did  not  object  to  the  baths.  When 
they  did  so,  their  objections  ceased  after  a  few  baths  had  been  admin- 
istered. Complications  were  trifling,  there  were  no  sequelae,  and  in 
every  case  the  convalescence  was  rapid  and  satisfactory." 

In  a  lecture  published  in  Lippincott's  International  Clinics,  for 
July,  1891,  page  19,  Dr.  Wilson  says :  "  This  treatment  has  consisted 
almost  exclusively  in  a  routine  procedure,  and  in  that  respect  is  wholly 
at  variance  with  the  general  teachings  of  this  country  in  regard  to  the 
management,  not  only  of  this  disease,  but  of  the  other  infectious  febrile 
diseases.  It  is,  moreover,  a  treatment  radically  different  from  any 
method  hitherto  practised  in  the  other  hospitals  to  which  you  have 
access,  and  is  only  briefly  discussed  in  your  text-books.  It  has  now 
been  systematically  and  continuously  carried  out  in  this  hospital  during 
a  period  of  sixteen  months,  and  our  studies  in  regard  to  it  embrace,  so 
far  as  I  am  informed,  a  longer  period  of  time  and  a  larger  number  of 
cases  than  in  any  other  American  hospital.  These  are,  collectively, 
sufficiently  large  to  warrant  a  review  of  our  work  at  this  time,  espe- 
cially as  our  results  coincide  with  those  which  have  been  placed  on 
record  upon  a  much  larger  scale  abroad. 

"  The  method  of  Brand  treated  with  indifference  outside  of  Ger- 
many, where  it  originated,  for  a  long  time  met  with  violent  and  sys- 
tematic opposition  in  the  country  of  its  birth.  By  degree  it  won  its 
way  to  favor,  step  by  step,  in  spite  of  this  opposition.  The  general 
testimony  in  regard  to  its  effect  upon  the  case  is  in  entire  accord  with 
the  statement  of  Brand." 

Dr.  Wilson*  reports  four  hundred  and  eight  cases  treated  by  sys- 
tematic bathing  in  the  German  Hospital  and  the  Hospital  of  Philadel- 
phia with  thirty-two  deaths  =  7.84  per  cent.  The  greatest  number  of 
cases  were  admitted  during  the  second  week  of  the  attack.  Hence 
the  strict  Brand  method,  which  demands  the  application  of  baths  dur- 
ing the  first  week,  could  not  be  applied. 

During  the  Cuban  war  Dr.  J.  C.  Wilson  f  treated  147  cases  of  enteric 

*  Medical  News,  November  30th,  1895. 

t  Philadelphia  Med.  Journal,  February  25th,  1899,  p.  409. 

13 


194       THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHEBAPY. 

fever  at  the  German  Hospital  with  a  mortality  of  3.4  per  cent.  Of  these 
121  were  treated  by  systematic  cold  bathing.  Considering  that  the 
average  duration  of  the  disease  upon  admission  was  eleven  days,  this 
result  is  remarkable.  At  the  same  meeting  Dr.  B.  F.  Stahl  (St.  Agnes 
Hospital)  reported  144  cases  with  5  deaths  (2.8  per  cent).  Every 
patient  having  a  temperature  of  102.2°  was  bathed  every  third  hour; 
the  total  number  of  baths  were  1,830.  The  work  was  much  facilitated 
by  an  ingenious  lifting  apparatus,  which  is  illustrated  in  the  Journal. 

Dr.  James  Tyson,  Professor  of  Clinical  Medicine,  University  of 
Pennsylvania,  thus  testifies  to  the  value  of  the  Brand  method:*  "I 
have  been  anxious  for  an  opportunity  to  give  emphasis  to  a  method  of 
treatment  which,  while  it  has  received  the  acknowledgment  of  the 
large  majority  of  hospital  physicians,  has,  for  various  reasons — some 
of  them  quite  potent — failed  to  come  into  that  general  use  which  its 
efficiency  demands  for  it;  and  I  have  thought  that  an  opportunity 
would  be  presented  here  of  reaching  many  who,  by  reason  of  their 
residence  outside  of  the  larger  cities,  have  not  had  their  attention 
called  so  forcibly  to  its  superior  advantages  as  was  needed  to  secure 
its  more  general  adoption  in  private  practice.  Further,  I  arn  able  also 
to  show  a  means  by  which  the  treatment  is  bereft  of  one  of  its  most 
serious  inconveniences.  I  allude  to  the  Brand  bath  method  of  treating 
typhoid  fever.  /  have  become  so  satisfied  from  my  personal  experience 
with  this  method  that  it  without  doubt  greatly  surpasses  any  other  in  the 
results  attained  by  it  that  I  feel  impelled  to  do  what  I  can  to  extend  its 
use. " 

In  his  report  on  typhoid  fever  among  the  soldiers  of  the  Cuban 
war  f  Dr.  Tyson  writes :  "  The  treatment,  outside  of  the  dietetic,  may 
be  fairly  said  to  have  been  the  cold  tub-bath  method  of  Brand.  My 
experience  with  the  Brand  treatment  has  in  no  way  diminished  my 
confidence  in  it,  as  the  best  available  method  for  treating  typhoid 
fever,  subject  to  the  limitations  which  good  sense  and  experience 
may  demand." 

Responding  to  an  inquiry  regarding  his  present  attitude  on  this 
subject,  Professor  Tyson  has  recently  written  to  the  author :  "  I  still 
use  the  Brand  method  whenever  possib'e.  Its  effect  is  practically  to 
make  serious  cases  less  serious  and  mild  cases  much  milder.  My  sta- 
tistics to  January  1st,  1906,  showed  a  mortality  of  7. 3  per  cent,  which 
is  astonishingly  near  those  of  Osier  at  Johns  Hopkins  and  Wilson  at 
the  German  Hospital,  the  former  having  7.3  per  cent  and  the  latter 
7.25  per  cent." 

In  the  Transactions  of  the  State  Medical  Society  of  Indiana  for 
1889,  Dr.  G.  C.  Smythe,  of  Indianapolis,  Ind.,  reports  two  hundred 

*  Therapeutic  Gazette,  July  15th,  1895.  \Loc.  cit. 


THE   FULL   BATH.  195 

and  eight  cases  of  typhoid  fever  treated  by  baths  by  himself  and  three 
colleagues,  with  five  deaths  (2.5  per  cent).  He  says  (page  8):  "No 
one  has  a  right  to  oppose  this  treatment  upon  purely  theoretical 
grounds.  He  who  does  so,  and  refuses  to  adopt  it,  signs  the  death 
warrant  of  twenty  individuals  out  of  every  hundred  with  this  disease, 
and  a  discriminating  public  will  hold  him  responsible." 

The  status  of  the  Brand  method  in  New  York  city  is  evident  from 
the  following: 

At  a  meeting  of  the  New  York  Clinical  Society,  Dr.  H.  P. 
Loomis  presented  a  valuable  summary  of  the  Brand  method  as  fol- 
lows :* 

"  To  the  present  treatment  of  this  disease  must  be  given  the  credit 
of  saving  over  fifty  per  cent  of  the  people  who  formerly  died,  for  the 
disease  certainly  does  not  average  any  milder  type  now  than  it  did  ten 
or  twenty  years  ago. 

"  To  the  Brand  bath  is  rightly  given  a  great  deal  of  credit  for  this 
decrease  in  mortality. 

"  At  all  the  hospitals  the  Brand  bath  when  given  is  ordered  when 
the  temperature  reaches  103°,  with  the  exception  of  the  Presbyterian 
Hospital,  when  it  is  given  for  a  temperature  of  102.5°.  At  the  other 
hospitals  the  only  exception  to  the  general  rule  is  when  Dr.  Peabody 
is  on  duty  at  the  New  York  Hospital,  when  he  orders  the  baths  for  a 
temperature  of  102.5°,  and  Dr.  James,  when  on  duty  at  Eoosevelt 
Hospital,  for  the  same  temperature.  Two  of  the  hospitals  (Presby- 
terian and  Belle vue)  give  the  baths  every  four  hours,  and  two  (Roose- 
velt  and  New  York)  give  them  every  three  hours.  The  temperature 
of  the  first  bath  in  all  the  hospitals  averages  70°.  All  the  children 
are  tubbed  at  a  higher  temperature,  viz.,  85°.  The  duration  of  the 
bath  is  fifteen  minutes,  and  whiskey  before  and  hot  milk  after  the  bath 
is  universally  given.  The  temperature  is  taken  in  all  the  hospitals  ex- 
cept the  Presbyterian  (one  hour)  one-half  hour  after  the  bath. 

"The  Brand  bath  should  be  given  in  all  cases  when  the  tempera- 
ture reaches  103°.  It  should  be  ordered  every  four  hours.  The 
technique  is  as  follows : 

"  The  patient  receives  f  ss.  of  whiskey  (diluted)  before  the  bath 
and  a  glass  of  hot  milk  after.  The  temperature  of  the  bath  should  be 
70°,  and  gradually  reduced  by  ice  to  65°.  The  patient  should  remain 
in  the  water  fifteen  minutes  and  should  be  constantly  rubbed.  A  cold 
compress  or  ice  cap  should  be  placed  on  the  head.  On  removal  from 
the  bath  the  patient  should  be  dried  off  by  a  sheet  which  is  removed, 
and  then  the  patient  is  wrapped  in  blankets.  At  the  end  of  half  an 
hour  the  temperature  is  taken  and  noted  on  the  chart,  the  effects  of 
*  Medical  Record,  January  10th,  1903. 


196        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

the  baths  being  recorded  by  a  red  line.  The  4  A.M.  bath  can  always 
be  omitted  with  advantage,  and  iii  most  cases  the  12  P.M.  bath  also." 

Only  a  few  days  prior  to  his  decease  this  lamented  teacher  Avrote 
to  the  author  of  his  continued  adherence  to  the  Brand  baths,  the  clos- 
ing lines  being  as  follows :  "  I  always  give  one  or  two  Brand  baths 
before  the  students  of  Cornell  Medical  College  in  Bellevue  Hospital, 
going  carefully  over  the  details." 

Prof.  J.  H.  Musser,  of  Philadelphia,  recently  wrote  to  the  author : 
"  I  favor  the  use  of  the  Brand-bath  treatment  in  typhoid-fever  cases 
because  we  get  the  best  results." 

Dr.  A.  B.  Ball,  Professor  of  Clinical  Medicine  in  the  same  school, 
thought  "  the  reason  why  the  doctors  at  Bellevue,  including  himself, 
had  given  up  the  bath  treatment  some  years  ago  was  that  they  did  not 
employ  rubbing.  Everybody  who  had  tried  the  more  recent  method, 
devised  by  Dr.  Baruch,*  adding  friction,  had  been  convinced  that  there 
was  110  other  method  at  command  which  ivas  so  valuable.  The  influ- 
ence upon  the  respiration,  causing  deep  inspiration,  must  be  among 
the  most  beneficial  effects.  With  women  he  had  continued  the  treat- 
ment during  menstruation,  and  it  had  received  the  approval  of  some 
of  his  gynaecological  friends  whom  he  had  consulted  about  it.  With 
some  patients  it  might  be  best  to  begin  the  bath  at  85°  or  even  90°  F. 
The  great  mistake  was  to  suppose  that  it  was  intended  simply  to  reduce 
the  temperature." 

Dr.  W.  P.  Northrup,  Professor  of  Paediatrics,  Bellevue  Hospital, 
said  "  the  beauty  about  the  bath  treatment  of  typhoid  cases  was,  to 
quote  Dr.  Delafield,  that  they  ran  such  a  comfortable  course.  He  had 
applied  it  in  all  cases  for  three  successive  autumns  at  the  Presbyterian 
Hospital,  except  in  a  few  cases  in  which  at  the  strong  recommendation 
of  a  doctor  in  the  city  he  allowed  Fraenkel's  toxin  to  be  tried.  These 
patients,  although  recovering,  suffered  such  great  discomfort  from  their 
disease  as  long  as  the  baths  were  withheld  that  he  made  up  his  mind, 
if  he  were  forgiven  for  thus  allowing  them  to  suffer,  never  to  repeat 
the  offence." 

Sir  William  Broadbentf  says:  "  While,  however,  cold  sponging,  the 
wet  compress,  the  ice  bag,  and  similar  measures  are  useful  and  grate- 
ful, they  fail  to  exercise  the  desired  control  over  the  temperature  when 
the  fever  is  at  all  severe.  A  resource  of  greater  power  is  the  bath, 
and  it  must  be  said  that  whenever  this  has  been  systematically  tried 
the  mortality  of  typhoid  has  been  considerably  reduced." 

It  would  seem  that  even  the  leaders  of  medical  thought  in  Great 

*  The  author  has  endeavored  to  emphasize  the  paramount  importance  of 
friction,  but  it  was  devised  by  Ernst  Brand  of  Stettin,  to  whom  all  honor  is 
due. 

t  Lancet,  1896,  vol.  ii.,  p.  426. 


THE   FULL   BATH.  197 

Britain  have  not  yet  disenthralled  themselves  from  antipyresis  and 
apply  the  cold  bath  as  an  antipyretic  still,  as  is  evident  from  the  excel- 
lent lecture  of  Dr.  Broadbent  from  which  the  above  extract  em- 
anates. 

Dr.  Tuttle*  states  that  "  in  the  New  York  Hospital  during  the  year 
ending  November  1st,  1892,  there  were  seventy-six  typhoid  patients 
treated  by  the  cold  bath,  with  a  mortality  of  only  five  per  cent.  The 
Brand  method  was  carried  out  more  perfectly  in  this  than  in  any  other 
hospital  in  the  city,  as  in  most  of  them  the  treatment  was  mixed,  in 
some  a  bath  being  given  when  the  patient  seemed  to  stand  the  high  tem- 
perature poorly,  and  in  others  baths  with  intestinal  antiseptics  and  other 
medication,  but  in  none  with  such  good  results  as  above."  The  fault 
referred  to  by  Dr.  Tuttle  is  very  prevalent,  the  fact  being  lost  sight  of 
that  the  ideal  results  of  Brand  can  be  expected  only  from  following 
strictly  his  method. 

Dr.  Osier,  Professor  of  Practice  in  the  Johns  Hopkins  Hospital,! 
gives  the  statistics  of  typhoid  mortality  for  six  years,  ending  May, 
1895 :  Cases  admitted  before  introduction  of  hydrotherapy,  33 ;  mor- 
tality 24.2  per  cent.  Cases  admitted  since  introduction  of  hydrother- 
apy, 356;  mortality  6.6  per  cent. 

"  Two  advantages  are  claimed  for  hydrotherapy  in  typhoid  fever — • 
a  mitigation  of  the  general  symptoms  of  the  disease  and  a  reduction 
in  the  mortality.  Our  experience  during  the  past  five  years  bears  out 
these  claims. 

"  In  general  hospitals,  to  which  cases  rarely  are  admitted  before  the 
end  of  the  first  week,  the  full  benefits  of  the  cold  bath,  as  described 
by  Brand,  cannot  be  expected ;  nevertheless,  in  any  large  series,  the 
severer  manifestations  appear  to  be  less  common.  As  has  been  urged 
so  often  and  so  ably  by  many  writers,  the  beneficial  action  is  not  so 
much  special  and  antipyretic  as  general,  tonic,  and  roborant.  The 
typhoid  picture  is  not  so  frequently  seen,  and  we  may  have  twenty  or 
more  cases  under  treatment  without  an  instance  of  dry  tongue  or  of 
delirium  among  them.  It  is  a  mistake  to  claim,  as  do  the  too  ardent 
advocates  of  the  plan,  that  severe  nervous  symptoms  are  never  seen. 
I  have  taken  the  pains  to  go  over  carefully  our  records  on  this  point. 
There  were  in  the  first  three  years  thirteen  cases,  in  the  past  two  years 
nine  cases  with  delirium. " 

While  Osier's  comments  are  correct,  the  fairness  of  this  statement 
may  be  enhanced  by  calling  attention  to  the  fact  that  the  "  ardent 
advocates  of  the  plan  "  claim  the  absence  of  severe  nervous  symptoms 
only  in  cases  in  which  strict  bathing  is  begun  very  early  in  the  disease. 
My  observations  demonstrate  the  correctness  of  this  claim  and  that 

*  Southern  Medical  Record,  1892.  f  Eeports,  vol.  v. 


198        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

the  earlier  bathing  is  begun  the  more  pronounced  is  the  abolition  of 
delirium  and  stupor.  Since,  however,  "  in  general  hospitals  cases  are 
rarely  admitted  before  the  end  of  the  first  week,  the  full  benefits  of 
the  bath  cannot  be  expected,"  as  Osier  says;  hence  the  claims  of  the 
"ardent  advocates,"  are  not  a  mistake. 

"A  far  more  important  claim  is  that  the  use  of  the  cold  bath  re- 
duces the  mortality  from  the  disease.  The  comparison  of  death  rates 
as  a  measure  of  the  efficacy  of  any  plan  of  treatment  is  notoriously 
uncertain  unless  all  the  circumstances  are  taken  into  account.  Our 
own  figures  for  the  past  five  years,  for  example,  illustrate  this:  6.2 
per  cent  in  the  bathed  cases,  ten  in  the  unbathed  cases — as  the  latter 
group  is  made  up  entirely  of  cases  too  mild  to  bathe — and  six  patients 
in  whom  either  the  disease  was  not  recognized  or  who  were  too  ill  on 
admission  to  treat. 

"  In  the  Metropolitan  Fever  Hospitals,  London,  the  death  rate,  as 
given  in  the  Report  for  1893,  was  seventeen  per  cent.  The  cold-bath 
treatment,  rigidly  enforced,  appears  to  save  from  six  to  eight  in  each 
century  of  typhoid  patients  admitted  to  the  care  of  the  hospital 
physician. 

"  While  I  enforce  the  method  for  its  results,  I  am  not  enamored  of 
the  practice.  I  have  been  criticised  rather  sharply  for  saying  harsh 
words  about  the  Brand  system.  To-day,  when  I  hear  a  young  girl  say 
that  she  enjoys  the  baths,  I  accept  the  criticism  and  feel  it  just;  but 
to-morrow,  when  I  hear  a  poor  fellow  (who  has  been  dumped,  like 
Falstaff,  '  hissing  hot '  into  a  cold  tub),  chattering  out  maledictions 
upon  nurses  and  doctors,  I  am  not  inclined  to  resent  it,  and  to  pray 
for  a  method  which  may  be,  while  equally  life-saving,  to  put  it  mildly, 
less  disagreeable." 

In  a  recent  reply  to  an  inquiry  by  the  author  Professor  Llewellen 
Barker,  of  Johns  Hopkins,  wrote :  "  We  feel  in  the  medical  clinic 
here,  at  the  Johns  Hopkins  Hospital,  just  as  Dr.  Osier  did,  that  the 
Brand  baths  are  of  great  advantage  in  typhoid  fever.  Typhoid  fever 
presents  an  entirely  different  picture  from  what  we  were  familiar 
Avith  before^  the  introduction  of  the  Brand  method. 

The  author  is  fully  in  accord  with  Dr.  Osiers  hope  that  a  more 
practical  and  agreeable  mode  of  saving  life  in  typhoid  fever  may  be 
devised. 

Dr.  Glenard,  Professor  of  Medicine  in  Lyons  University,  who,  as 
a  prisoner  of  war  in  Stettin,  assisted  Brand  in  treating  typhoid  fever 
among  the  French  prisoners,  and  on  his  return  to  France  became  a 
warm  propagandist  for  the  Brand  method,  concludes  a  paper  before  the 
French  Congress  for  Internal  Medicine,  1894,  as  follows :  "  The  treat- 
ment of  typhoid  fever  with  cold  water  has  not  only  resisted  all  on- 
slaughts against  it  in  France,  but  its  value  is  so  far  undisputed 


THE   FULL   BATH. 


199 


that  many  Parisian  professors  regard  it  as  a  specific.  Easily  executed 
in  town  and  country,  in  the  house  of  the  poor  as  well  as  of  the  rich, 
the  remedy  should  become  the  common  property  of  all  physicians,  and 
our  hospitals  should  afford  ample  material  for  its  thorough  mastery." 

Dr.  F.  H.  Hare,  of  the  Brisbane  Hospital,  Queensland,*  offers  an 
excellent  resume  of  the  work  of  a  large  general  hospital.  From  1882 
to  1887,  1,828  cases  of  typhoid  fever  were  treated  on  the  expectant 
plan,  with  a  mortality  of  14.8  percent.  From  1887  to  1896,  one  hun- 
dred and  ninety  cases  were  treated  with  the  Brand  system  (?)  of  celd 
bathing  with  a  mortality  of  7.5  per  cent.  There  has  occurred,  there- 
fore, a  reduction  in  the  mortality  of  the  disease  of  practically  fifty  per- 
cent; or,  in  other  words,  about  seven  of  every  one  hundred  patients 
admitted  have  been  saved  by  the  bath  treatment.  This  result  har- 
monizes exactly  with  the  latest  conclusion  of  Osier  on  this  subject. 
He  says:  " The  cold-bath  treatment  rigidly  enforced  appears  to  save 
from  six  to  eight  in  each  century  of  typhoid  patients  admitted  to  the 
care  of  the  hospital  physician. 

"  The  series  being  sufficiently  long  to  exclude  errors  due  to  paucity 
of  data,  the  variations  have  practically  disappeared;  there  is  instead, 
as  pointed  out  by  Osier,  a  remarkable  uniformity  in  the  results. 

"  The  most  important  result  of  the  systematic  employment  of  Brand's 
treatment  is  the  alteration  it  has  effected  in  the  constitution  of  the 
mortality  list.  The  statistics  of  the  first  three  years  of  the  decade  led 
to  the  conclusion  that  the  treatment  was  ineffectual  to  reduce  the  mor- 
tality from  perforation  and  hemorrhage,  and  that  the  vast  bulk  of  the 
reduction  was  due  to  the  prevention  of  those  complications  and  modes 
of  death  which,  being  more  or  less  common  to  the  febrile  state  however 
induced,  are  termed  pyrexial.  Further  experience  has  simply  verified 
this. 

"In  the  1,902  cases  of  the  ten-years'  bath  period,  56  patients  died 
of  perforation,  or  2.9  per  cent;  23  of  hemorrhage,  or  1.2  per  cent; 
while  64,  or  3.4  per  cent,  succumbed  to  other  causes.  The  following 
table  shows  the  modification  which  has  been  imprinted  upon  the 
constitution  of  the  typhoid  mortality  list  by  the  introduction  of  the 
cold-bath  treatment: 


Causes  of 
Death  iu  Typhoid. 

According 
to  Murchison. 
Percentage. 

Brisbane  Hospital 
before  Introduction  of 
Bath  Treatment. 
Percentage. 

Brisbane  Hospital 
after  Introduction  of 
Bath  Treatment. 
Percentage. 

Perforation  ...... 

3 

2  9 

2  9 

Hemorrhage  
Other  causes  

1.4 
12.8 

1.88 
9.73 

1.2 
3.4 

Total  mortality. 

17.2 

14.5 

7.5 

*  Medical  Record,  May  8th,  1897. 


200       THE   PRINCIPLES  AND   PRACTICE   OF   HYDRO-THERAPY. 

"  Thus  almost  the  whole  of  the  reduction  in  mortality,  amounting  to 
seven  in  every  one  hundred  admitted,  falls  upon  the  third  group  of 
causes ;  or,  in  other  words,  perforation  and  hemorrhage,  which  together 
used  to  cause  only  about  one-fourth  of  the  total  deaths,  now  under  the 
bath  treatment  cause  more  than  half,  and  this  in  spite  of  the  fact  that 
they  are  if  anything  actually  less  fatal. 

"  An  important  point  brought  out  by  this  report  is  the  comparative 
mortality  of  the  sexes.  Statistics  on  a  large  scale  show  that  under 
ordinary  treatment  the  female  mortality  is  slightly  higher  than  the 
male.  In  Brisbane,  during  the  expectant  period,  1,160  men  and  C68 
women  were  admitted.  Of  the  former  164  died,  a  mortality  of  14.14 
per  cent;  of  the  latter  107,  a  mortality  of  16.02  per  cent.  The  differ- 
ence is  in  spite  of  the  admitted  fact  that  men  are  about  twice  as  liable 
as  women  to  succumb  to  perforation  and  hemorrhage. 

"  It  follows,  therefore,  that  the  female  wards  offer  a  better  field  for 
the  cold-bath  treatment  than  the  male." 

These  statistics  present  almost  exactly  the  same  result  as  those  of 
the  second  division  of  Vogl's  hospital,  in  which  the  same  mixed  treat- 
ment was  pursued.  They  are  equally  valuable,  because  all  sources  of 
error  are  eliminated  in  this  judicious  report.  It  may  be  of  interest 
again  to  refer  to  the  fact  brought  out  by  Brand,  that  perforation  and 
hemorrhage  are  prevented  only  by  the  strict  early  cold  bathing.  The 
reason  for  the  absence  of  reduction  of  these  complications  in  the  Bris- 
bane Hospital  rests  on  the  fact  that  in  a  general  hospital  cases  are  not 
admitted  before  the  fifth  day,  and  in  the  Brisbane  Hospital  the  treat- 
ment is  mostly  a  combination  of  the  Brand  method  with  antipyretics. 

Bouveret  records*  one  hundred  cases  of  typhoid  fever  treated  by 
the  strict  cold  bath,  with  a  mortality  of  three  per  cent.  The  average 
date  of  admission  of  the  fatal  cases  was  the  sixteenth  day.  He  com- 
mences in  advanced  cases  at  79°  or  80°  F.,  reducing  the  temperature 
of  the  baths  to  Brand's  standard  of  65°,  if  fever  does  not  yield.  He 
has  never  had  syncope  or  heart  failure  from  the  bath,  because  he  never 
omits  friction  over  the  body,  except  over  the  abdomen.  He  treats 
strictly  in  accordance  with  Brand's  rules,  except  that  the  abdominal 
wet  compresses  are  kept  cold  by  ice  bladders  contained  within  them. 

A  popular  work  on  practice, f  published  in  Great  Britain,  shows 
that  even  in  conservative  England  (see  page  526)  the  Brand  method  is 
arousing  attention.  "  Treatment  against  temperature  (?).  Quinine  is 
the  best  medicinal  agent;  coal  tars  are  to  be  avoided.  Hydrotherapeu- 
tic  means  have  been  used  with  more  success.  Of  these  the  Brand  sys- 
tem is  by  far  the  most  important,  and  although  it  has  never  had  a  fair 

*  Lyon  Medicale,  1891. 

•(•Gibson's  "Practice  of  Medicine,"  by  eminent  authors.  Edinburgh  and 
London  :  J.  Pentland,  1901 


THE   FULL   BATH.  201 

trial  in  this  country,  it  has  given  admirable  results  on  the  Continent  and 
in  America.  In  spite  of  the  apparent  severity,  the  death  rate  of  ty- 
phoid fever  has  been  considerably  lowered  in  all  hospitals  where  it  has 
been  systematically  used.  The  great  secret  of  its  success  would  ap- 
pear to  lie  in  the  fact,  not  that  it  lowers  temperature,  but  that  it  pro- 
duces elimination.  Diuresis  is  much  more  free  and  the  toxins  are  dis- 
charged in  much  greater  quantity." 

The  last  sentence  quite  contradicts  the  first  line  of  this  quotation, 
and  proves  how  firmly  implanted  is  the  idea  that  a  cold  bath  is  "  a 
treatment  against  temperature." 

Private  Practice. — Thus  far  the  observations  of  hospital  physicians 
and  teachers  only  have  been  cited.  Although  these  include  their  ex- 
perience in  private  practice,  the  following  statements  from  physicians 
in  private  practice  alone  may  be  of  interest. 

In  an  essay  read  before  the  Detroit  Medical  Association  and  pub- 
lished in  The  Physician  and  Surgeon,  December,  1889,  Dr.  Carl  Born- 
ing  says :  "  In  reviewing  sixty-one  cases — which  I  have  treated  with- 
out a  death  by  Brand's  method,  with  no  medicine  except  one  or 
two  large  initial  doses  of  calomel — I  have  to  say  most  emphatically 
and  decidedly  that  Dr.  Brand's  method  of  treating  with  cold  baths 
typhoid  fever  or  typhus  fever,  or  in  fact  all  diseases  with  a  continuous 
abnormally  high  temperature,  is  the  very  best,  the  ideal  mode  of  treat- 
ment, and  the  one  which  should  be  pursued  in  every  case,  may  it  be 
severe  or  mild.  If  this  plan  is  persisted  in  from  the  beginning,  no 
anxiety  need  ever  be  felt  by  the  physician  about  his  patient,  for  he  will 
surely  recover.  The  course  of  the  disease  will  be  relatively  mild,  and 
all  these  various  and  dreadful  complications  which  are  so  common  with 
any  other  plan  of  treatment  will  be  almost  entirely  excluded.  But 
in  order  to  get  these  results  you  have  to  carry  out  Brand1 s  directions  to 
the  letter. " 

Dr.  Barker,  of  St.  Louis,  f  states  that  he  has  treated  forty -five  cases 
in  private  practice,  thirty-five  of  which  received  baths  of  70°  or  75° 
for  fifteen  minutes.  In  the  latter  he  had  not  a  single  death.  Barker 
has  abandoned  sponging,  rubbing  with  ice,  etc.,  for  "  immersion,  which, 
although  troublesome  at  first,  requires  less  skill  and  can  be  relied  on 
for  pronounced  effect." 

Dr.  Carl  Sihler,  of  Cleveland,  Ohio,  was  so  firmly  convinced  of  the 
life-saving  value  of  the  Brand  method  in  typhoid  fever  that  he  under- 
took, at  his  own  expense,  the  work  of  translating  Brand's,  Yogi's,  and 
Tripier's  contributions,  because  "here  was  a  chance  for  missionary 
work  in  a  field  which  promised  many  good  results."  He  justly  says 
that,  while  his  personal  experience  "  covers  the  first  period  with  the 

*  Therapeutic  Gazette,  p.  515.  1895. 


202       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

water  treatment,  when  serving  my  apprenticeship,  and  shortcomings 
and  mistakes  in  the  application  of  the  method  would  be  apt  to  make 
such  observations  of  little  value,"  it  demonstrates  clearly  "with  what 
degree  of  accuracy  and  how  extensively  an  ordinary  practitioner  in 


TABLE  OF  COMPARATIVE  MORTALITY  UNDER  VARIOUS  METHODS  OP  TREAT- 
MENT IN  TYPHOID  FEVER. 


Reporter. 

Source. 

Treatment. 

Number 
of 

Cases. 

Percentage 
of 
Mortality. 

Various  sources  

Expectant  

80,140 
27,051 
11,124 
1,305 

229 
5,484 

1,828 

271 
629 
376 

2,841 

19,017 
1,000 
2,000 

702 
1,173 
1,902 

145 
144 

428 
141 
100 

2,198 
2,150 

94 

408 

426 

76 
80 
35 
61 
52 
173 

368 
900 

19.25 
17.45 
21.7 
34.66 

262 
20.7 

14.82 

13.29 
16.5 
6.9 

12.2 

7.8 
8.5 
9.6 

7.6 
7.84 
7.05 

6.9 
4.1 

S.7 
3.5 
3 

1.7 
0 

7.8 
8.4 

5 
5 
0 
0 
1 
5.4 
7.25 
6.8 

7i75 

Murchison  — 
Brand  

Various  sources  
Various  sources  

Expectant  

Expectant  

Delafield     .... 

New  York  Hospitals,  1878- 
83. 
Lyons  Hospital,  1866-77. 
Munich  Military  Hospital, 
1841-78. 
Brisbane    Hospital,    1882- 
87. 
German  Hospital,  Phila.  .  . 
Lyons  Hospital,  1873-81  .... 
Lyons  Hospital,  1882-87.  .  .  . 

Munich     Military    Hospi- 
tal, 1868-81. 
Various  sources  

Expectant  

Tripier    

Expectant    

Vogl  

All  kinds,  chiefly  expectant  . 

Expectant,  quinine,  and  cold 
wet  sheet. 
Expectant  and  some  baths.  . 
Expectant  and  bathing  
Strict  baths  in  severe  cases. 

Expectant  and  baths  

Hare  

Wilson  

Tripier  

Bouveret  and 
Teissier. 
Vogl  

Brand  

All  kinds  of  cold  baths  

Riess    .... 

Permanent  tepid  baths  

Ziemsseii    .... 

Tiibingen  Clinic  

Graduated  baths  and  anti- 
pyretics. 
Strict  cold  baths  and  anti- 
pyretics. 
Cold  baths  and  some  anti- 
pyretics. 
Strict  Brand  

Vogl  

Munich  Military  Hospital, 
1877-87. 
Brisbane     Hospital,    1875- 
81. 
Brisbane    Hospital,    1887- 
96. 
Konigsberg  Clinic  

Hare    

Naunyn  

Strict  cold  baths        

Vogl  

Munich  Military  Hospital 
(3d  division),  1882-87. 
Munich   Military  Hospital 
(1st  division),  1880. 
Munich  Military  Hospital, 
1882-87. 
Lyons  Red  Cross  Hospital, 
1891. 

More  strict  baths  and   less 
antipyretics. 
Strict  cold  baths  

Vogl   

Vogl  

Strict  cold  baths  

Bouveret  
Brand  

Strict  cold  baths  

Brand  

Same  cases,  omitting  those 
not  treated  before  fifth 
day. 
jerman  Hospital,  Phila.  .  . 
German  Hospital,  Phila.  .  . 

Munich  Military  Hospital, 
1893. 
Sew  York  Hospital,  1893.. 

Strict  cold  baths  

Wilson,  J.  C.  .  . 
Wilson,  J.  C.  .  . 

Vogl   

Strict  cold  baths  

Baths  of  59°  

Tuttle  

Strict  cold  baths  

Sihler  

Barker  
Borning  

Private  practice  
Private  practice  

Strict  cold  baths  

Strict  cold  baths  

Murtra  

Strict  cold  baths  

•Tyson,  J  
Thompson,  W. 
H. 
Osier    

Jniversity  Hospital,  Phila.. 
Roosevelt   Hospital,  N.  Y. 

Strict  cold  baths  

Strict  cold  baths  

1889-99. 
lohns  Hopkins  Hospital  — 
New  York  and  Presbyterian 
Hospitals. 

Strict  cold  baths  

IF  i  1  ma  n 
Thompson. 

Strict  cold  baths  

private  practice  is  able  to  follow  "  this  method,  even  among  the  labor- 


THE   FULL   BATH.  203 

ing  classes.  During  two  years  Dr.  Sihler  treated  fifty-four  cases  of 
typhoid  fever  with  water,  with  three  deaths,  and  twenty-six  mild  cases, 
some  of  which  had  baths,  with  but  one  death;  and  concludes  by  say- 
ing :  "  With  this  method  a  powerful  means  for  good  is  placed  in  the 
hands  of  the  physician,  and  I  would  no  more  think  of  placing  any 
one  dear  to  me  personally,  suffering  from  typhoid  fever,  into  the  hands 
of  a  physician  who  does  not  act  according  to  the  principles  of  Brand, 
than  one  who  had  to  undergo  an  operation  into  the  hands  of  a  surgeon 
who  does  not  act  according  to  the  principles  of  Lister." 

W.  Gilman  Thompson  writes :  *  "  The  Brand  system  of  bathing  as 
applied  in  this  country  gives  astonishingly  uniform  results.  For 
example:  Johns  Hopkins  Hospital,  7.5  per  cent;  Philadelphia  Hospi- 
tals (Wilson  and  Tyson),  7.3  per  cent;  Eoosevelt  Hospital,  New 
York,  368  cases  (1889-99),  6.8  per  cent;  New  York  Hospital  and  Pres- 
byterian Hospital,  900  cases,  6.5  per  cent  (previous  mortality,  16.1  per 
cent) — 7.75  per  cent.  Hence  it  must  be  admitted  that  cold  tub  bath- 
ing reduces  the  general  typhoid  mortality  fully  one-half,  which  cer- 
tainly more  than  compensates  for  the  discomfort,  trouble,  and  expense 
attending  this  process. 

Since  adopting  the  strict  Brand  method  I  have  treated  about  one 
hundred  successive  cases  in  private  practice,  with  one  death,  while 
during  the  last  year  of  the  expectant  and  antipyretic  treatment  I  lost 
thirty-three  per  cent  of  my  private  typhoid  cases.  In  consultation 
practice  cases  are  seen  too  late  to  obtain  the  full  result  of  the  method. 
The  latter  cannot  be  used  with  exact  technique  because  the  reactive 
capacity  has  not  been  maintained  by  early  hydriatric  measures.  Never- 
theless, the  judicious  adaptation  of  the  latter  to  the  individual  case 
offers  encouragement,  f 

The  accompanying  table,  which  I  have  gathered  with  care  to  ex- 
clude all  unreliable  statistics,  presents  at  a  glance  the  comparative 
merits  of  the  various  methods  of  treatment.  The  figures  astounded 
me  when  I  sought  them  out,  and  I  trust  that  the  lesson  they  teach  will 
be  impressed  indelibly  upon  the  mind  of  the  reader. 

REASONS  FOR  THE  THERAPEUTIC  SUPREMACY  OF  THE  COLD  BATH  IN 
INFECTIOUS  FEVERS. 

While  statistics  have  demonstrated  the  superiority  of  the  Brand 
method,  it  is  well  that  physicians  divest  themselves  of  the  empirical 
influence  of  mere  figures,  which,  it  has  been  said,  may  be  marshalled 

*" Text-Book  on  Practical  Medicine,"  1902,  Lea  Brothers  &  Co.,  p.  45. 
f'Some  Desperate  Cases  of  Typhoid  Fever  Treated  With  and  Without 
Baths."     Medical  Record,  October  1st,  1890. 


204       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

in  any  cause  to  prove  anything,  and  investigate  the  reason  why  the 
cold-bath  treatment  of  typhoid  fever  is  superior  to  the  antipyretic, 
expectant  plan.  Therefore  I  do  not  ask  the  acceptance  of  the  evidence 
furnished  alone,  although  it  will  doubtless  be  conceded  that  never  in 
the  history  of  medicine  have  statistics  of  such  magnitude,  from  such 
reliable  and  diversified  sources,  been  brought  to  bear  upon  a  question 
of  therapeutics. 

The  idea  that  high  temperature  is  the  chief  determining  cause  of 
fatality  in  typhoid  fever  must  now  be  abandoned.  The  sooner  we  cut 
loose  from  this  fallacy  the  better  will  it  be  for  suffering  humanity. 
This  position  is  fortified  by  the  observations  of  many  clinical  observers 
and  by  experimental  laboratory  demonstrations.  Among  the  latter 
we  find  the  clear  and  sagacious  review  of  the  pathology  of  fever  by 
Professor  Welch,  of  Johns  Hopkins  University,  offered  in  his  Cart- 
wright  Lectures,  1888,  in  which  he  gives  a  cautious,  painstaking,  and 
judicious  weighing  of  all  the  evidence  bearing  upon  the  lethal  influence 
of  heat  elevation  in  fevers,  sustaining  them  by  experimental  and  clini- 
cal data  that  must  be  convincing  to  any  unbiassed  mind.  He  says,  in 
summing  up,*  that  "the  conclusion  seems  justifiable  that  failure  of  the 
heart  power  is  less  an  effect  of  high  temperature  than  of  other  concomi- 
tant conditions.  The  lessened  perspiration,  the  renal  disorders,  and 
the  digestive  disturbances  (with  the  possible  exception  of  constipation) 
are  referable  also  chiefly  to  other  causes  than  the  increased  tempera- 
ture. Both  experimental  and  clinical  observations  strongly  support  the 
view,  now  widely  accepted,  that  the  disturbances  of  the  sensorium, 
which  constitute  so  prominent  a  part  of  the  group  of  so-called  typhoid 
symptoms,  are  dependent  in  a  far  higher  degree  upon  infection  or  in- 
toxication than  upon  the  heightened  temperature.  Even  in  fever,  such 
as  typhoid  fever  and  pneumonia,  when  the  height  of  the  temperature  is 
undoubtedly  a  most  important  index  of  the  severity  of  the  disease, 
there  exists  no  such  parallelism  between  the  temperature  and  the  nature 
and  severity  of  the  symptoms  as  we  should  expect  if  these  symptoms 
were  caused  by  the  increased  heat  of  the  body." 

In  the  discussion  of  a  paper  on  antipyretics  which  I  had  the  honor 
to  read  before  the  section  on  practice  of  the  New  York  Academy  of 
Medicine,  the  lamented  Dr.  Wesley  Carpenter  said :  "  With  regard  to 
heart  failure  and  degeneration  of  the  muscular  fibres  of  the  heart,  I 
had  an  opportunity,  in  connection  with  the  pathological  department  of 
Bellevue  Hospital,  to  examine  microscopically  the  cardiac  muscle  in  a 
sufficient  number  of  cases  to  make  it  quite  evident  that  they  did  not 
occur  with  the  frequency  one  might  be  led  to  expect  from  reading  the 
writings  of  the  German  observers. " 

*  Medical  Record,  April  28th,  1888. 


THE   FULL   BATH.  205 

Dr.  A..  L.  Loomis  said  on  the  same  occasion :  "  I  am  not  certain, 
for  I  have  been  in  the  line  of  observation  similar  to  that  of  Dr.  Car- 
penter, that  failure  of  the  heart  is  due  to  pareuchymatous  degen- 
eration, of  which  we  have  at  times  heard  so  much,  and  it  has  seemed 
to  me  to  be  due  to  failure  in  nervous  supply  as  much  as  to  muscular 
changes. " 

This  is  clear  evidence  from  pathologists  and  clinicians,  which  I 
might  corroborate  by  other  home  and  foreign  testimony. 

Since  it  may  now  be  regarded  as  an  established  fact  that  high  tem- 
perature, minus  infection,  does  not  produce  those  serious  degenerations 
formerly  ascribed  to  it,  we  must  seek  in  the  infective  process,  and  the 
ptomaine  intoxication  resulting  from  it,  those  deleterious  effects  upon 
the  vital  organs  which  undermine  the  system  and  eventually  cause 
death  in  typhoid  fever.  As  the  chapter  on  its  rationale  has  clearly 
pointed  out,  the  cold-bath  treatment  yields  the  most  triumphant  results 
in  combating  these  very  effects  of  the  infective  and  toxic  agencies,  of 
the  true  entity  of  which  we  have  not  yet  positive  evidence.  It  has 
been  clearly  demonstrated  by  numerous  trustworthy  observers  that  the 
reflex  stimulus  aroused  by  the  shock  to  the  extensive  peripheral  nerve 
endings  so  energizes  the  nerve  centres  which  furnish  innervation  for 
circulation,  respiration,  digestion,  tissue  formation,  and  excretion, 
that  the  system  is  enabled  to  tide  over  the  dangers  which  would  ensue 
from  failure  of  these  functions. 

This  is,  in  a  nutshell,  the  effect  of  cold  bathing  in  infectious  fevers ; 
the  simple  cooling  effect  on  the  blood  occupies  a  secondary  though  not 
unimportant  office. 

The  refreshing  effect  of  the  cold  full  bath  upon  the  nerve-centres 
referred  to  produces  a  vigorous  cardiac  action,  which  is  evinced  by  the 
slower  and  more  regular  pulse  and  an  improved  tension  of  the  vessels, 
and  appetite  and  digestion  are  enhanced,  enabling  us  to  enforce  a  more 
perfect  nutrition;  it  deepens  and  lowers  the  respiration,  preventing 
stasis  of  bronchial  secretions  and  obviating  pulmonary  complications; 
all  the  secretions  are  enhanced;  the  patient  is  refreshed  and  invigo- 
rated, and  fifjlds  the  battle  of  life  with  all  chances  in  his  favor.  How 
different  is  the  aspect  of  a  case  under  the  expectant  treatment,  and 
how  different  is  the  effect  of  pure  antipyretic  medication !  The  tem- 
perature may,  indeed,  be  reduced,  but  the  stimulating  effect  upon  the 
nerve  centres  and  secretion,  except  on  the  perspiration,  is  absent. 
Vinay,*  who  has  made  some  creditable  investigations  on  the  subject, 
tells  us  that  antipyrin  does  not  relieve  the  delirium,  which  is  in  accord- 
ance with  my  own  observation ;  it  does  not,  like  the  cold  bath,  increase 
the  flow  of  urine,  by  which  noxious  elements  are  eliminated.  He 
*Lyon  Medicale,  1888. 


206        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

has  also  confirmed  Vogl's  observation  that  convalescence  is  much  short- 
ened, because  there  is  a  rapid  gain  of  weight  when  the  fever  has  been 
treated  by  cold  baths.  Kairin,  resorcin,  and  antipyrin*  diminish  the 
excretion  of  urea  and  nitrogen ;  hence  they  diminish  the  excretion  of 
the  materies  morbi  through  the  kidneys,  while  baths  increase  it.  The 
liver  in  patients  dying  after  treatment  by  antipyrin  is  from  six  to 
twelve  and  one-half  grams  heavier  than  in  those  dying  after  cold  baths. 
This  is  confirmed  by  Dr.  Porter,  f  who  found  that  antipyretics  produced 
granular  and  fatty  metamorphosis  of  the  liver  and  kidneys.  Indeed, 
there  is  an  entire  absence  of  good  effect  upon  the  circulation  after  an- 
tipyrin, an  effect  which  is  marked  after  the  cold  bath. 

In  the  discussion  of  this  subject,  at  the  instance  of  Dujardin- 
Beaumetz,  by  the  Paris  Congress  of  Therapeutics  a  few  years  ago, 
Lepine  stated  that  his  investigations  showed  conclusively  that  all  anti- 
pyretics, the  effect  of  which  is  so  palpably  soothing  to  the  nervous 
system,  act  by  inhibiting  the  activity  of  the  protoplasm ;  they  destroy 
chiefly  the  red  corpuscles,  either  by  converting  the  hemoglobin  or  by 
attacking  the  cell  structure  itself;  they  act  as  poison  to  the  protoplasm. 
Desplats,  though  favoring  medicinal  antipyretics  in  fevers  of  short 
duration,  favored  most  decidedly  the  strict  cold  bathing  of  Brand  in 
continued  fevers  with  a  tendency  to  adynamia  or  ataxia.  Stokvis  and 
Semmola  spoke  of  medicinal  antipyretics  as  dangerous  remedies. 
Semmola  thought  that  whatever  comfort  is  induced  by  them  is  pur- 
chased at  the  expense  of  weakening  the  patient. 

The  matter  stands  quite  differently  with  the  Brand  method,  which 
even  in  the  modified  and  emasculated  forms  which  prevail  is  far  more 
effective. 

Dr.  Shattuck,  Jackson  Professor  of  Practice  in  Harvard  University, 
says!  it  is  certain  that  the  modified  and  feeble  bath  treatment  practised 
in  this  country  cannot  compare  in  results  with  the  strict  Brand  method, 
because  the  former  still  shows  a  mortality  of  ten  per  cent. 

Dr.  Horatio  C.  Wood,  who,  as  Professor  of  Therapeutics  in  the 
University  of  Pennsylvania,  may  be  regarded  as  a  safe  counsellor, 
Bays  with  reference  to  Brand's  method:  "I  have  no  doubt  that  very 
many  persons  in  the  United  States  have  died  of  typhoid  fever  whose 
lives  would  have  been  saved  if  the  American  medical  profession  had 
risen  above  the  opposition  of  the  laity  and  above  its  own  prejudices." 

Dr.  Blackader  §  reports  an  epidemic  of  typhoid  fever  among  chil- 
dren in  Montreal,  produced  by  infected  milk.  Fifty-three  cases  were 
treated  in  hospital,  and  twenty-nine  in  private  practice.  In  the  ma- 

*  According  to  Jacubowitch,  Jahrbuch  fur  Kinderheilkunde,  1885,  and 
other  authorities. 

t  New  York  Medical  Journal,  July  30th,  1887. 

\  Boston  Medical  and  Surgical  Journal,  p.  604,  1894. 

§  Archives  of  Paediatrics,  September,  1900. 


THE   FULL   BATH.  207 

jority  of  these  cases  cold  baths  were  used  when  the  body  temperature 
reached  103.2°.  The  bath  lasted  ten  minutes  and  was  repeated  every 
three  hours.  This  author  is  convinced  of  the  great  value  of  cold  and 
cool  baths,  which  should  aim  chiefly  to  invigorate  the  heart,  improve 
the  respiration  and  secretion.  The  nervous  system  of  a  child  reacts 
more  promptly  to  the  cold  bath,  in  inverse  ratio  to  the  age.  The 
temperature,  duration,  and  number  of  baths  must  be  adapted  to  each 
case;  as  a  general  thing  the  bath  should  be  somewhat  warmer  than  in 
adults.  While  bath  temperatures  of  68°,  and  even  75°,  may  produce 
great  shock  in  a  child,  baths  of  89°,  cooled  down  to  85°,  never  pro- 
duce collapse.  The  more  advanced  the  disease,  the  lower  may  the  bath 
temperature  be.  When  the  body  temperature  is  below  102.5°,  one  or 
two  daily  cool  baths  improve  cardiac  action  and  hasten  convalescence. 

Juhel-Renoy,  the  late  eminent  Parisian  physician,  claims  that  even 
in  old  people  the  only  effectual  treatment  is  by  the  cold  bath,  from 
which  he  has  obtained  such  marvellous  results  that  they  amounted  to 
"resurrections"  in  some  cases.* 

Dr.  H.  A.  Hare,  Professor  of  Therapeutics  in  Jefferson  Medical 
College,!  furnishes  a  judicious  exposition  of  this  subject.  On  page  62 
he  says :  "  The  writer  feels  sure  that  antipyrin  should  be  given  in  ty- 
phoid and  other  low  fevers  of  a  continued  type  only  when  the  cold 
pack  [with  which  he  evidently  includes  bathing]  cannot  be  used,  or  at 
the  end  of  the  cold  application,  to  prevent  the  temperature  from 
bounding  upward  after  its  depression.  Xo  fever  can  resist  the  cold 
bath.  Cold  bathing  is  a  power  for  good,  before  which  every  other 
measure  must  stand  aside." 

Professor  Gerhardt  opened  his  course  of  lectures  in  the  Berlin  Uni- 
versity on  medicine  in  the  fall  of  1896  by  a  lecture  on  "  Prognosis  of 
Disease,"  in  which  he  stated  that  the  "prognosis  of  typhoid  fever  has 
been  changed  by  treatment,  the  mortality  of  this  disease  having  been 
reduced  by  the  Brand  cold-water  treatment  to  one-fourth  its  former 
rate." 

Since  the  fact  has  been  demonstrated  that  cold  baths  are  antifebrile 
remedies,  while  antipyretics  are  simply  antithermic  agents,  the  supe- 
riority of  the  former  over  treatment  by  antipyretic  medication  is  thus 
made  clear. 

A  mixed  treatment  is  advocated  by  Liebermeister  and  Ziemssen. 
The  latter,  who  is  one  of  the  stanchest  defenders  of  the  cold  bath  (not, 
however,  as  an  antipyretic  alone),  regards  the  gradually  lowered  bath 
as  better  adapted  to  the  exigencies  of  private  and  civil  practice,  while 

*  Bulletin  de  Therapie,  p.  530,  1895. 

fBoylston  prize  essay  on  "Fever:  Pathology  and  Treatment  by  Antipy- 
retics. " 


208        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

he  concedes  that  the  results  of  Vogl  and  others,  in  military  practice, 
leave  nothing  to  be  desired.  Liebermeister  has  until  very  recently  in- 
sisted upon  the  cold  bath  as  an  antipyretic  to  produce  remissions  in  the 
fever,  and  has  prescribed  quinine  to  render  these  more  enduring. 
Naunyn,  on  the  other  hand,  uses  a  modified  and  more  temperate  bath- 
ing, rejecting  all  antipyretic  medication. 

Testimony  of  Eminent  Teachers. — In  the  fourth  Congress  of  Inter- 
nal Medicine  (1885),  eminent  clinicians  expressed  almost  unanimously 
the  opinion  that  "  until  we  obtain  a  specific  curative  agent  for  typhoid 
fever,  such  therapeusis  is  to  be  preferred  as  is  capable  of  diminishing 
or  removing  the  effects  of  the  morbific  agents,  and  that  this  aim  is 
most  surely  fulfilled  by  hydrotherapy ;  that  medicinal  antipyretics  act 
only  against  temperature  elevation,  but  do  not,  like  the  bath,  produce 
a  modifying  effect  upon  the  fever  process."  Fielehne,  Liebermeister, 
Jacksch,  Strumpell,  Eossbach,  Heubner,  Jlirgensen,  Bamberger,  were 
among  the  speakers  on  the  occasion,  and  were  instrumental  in  producing 
a  reaction  in  favor  of  the  bath,  which  was  about  to  be  swept  away  in  the 
antagonism  which  antipyretic  medicines  in  typhoid  fever  had  justly 
evoked.  (See  Corroboration  by  American  teachers,  pages  192  to  195.) 

Character  of  Statistical  Evidence. — There  is  a  statistical  bureau  in 
Berlin  which  sifts  carefully  all  statistics  pertaining  to  medicine.  In 
1887  Guttstadt,  who  was  its  censor,  said  in  a  lecture  before  the  Verein. 
filr  innere  Medicin  in  Berlin :  "  An  important  factor  in  the  diminution 
of  mortality  is  the  more  successful  treatment  now  used,  especially 
Brand's  method." 

As  corroborative  and  explanatory  of  the  reasons  of  the  superiority 
of  the  bath  treatment,  a  valuable  lesson  is  inculcated  by  the  unique 
reports  of  Dr.  A.  Vogl,  who  is  the  chief  of  the  garrison  hospital  at 
Munich.  He  has  collected  from  the  records  of  that  hospital  all  the 
cases  of  typhoid  fever  treated  in  it  for  forty-seven  years,  giving  de- 
tails of  treatment,  autopsy  findings,  and  other  valuable  data  in  8,325 
cases.  The  gross  results  are  noted  in  the  table  given  above.  But 
the  most  important  deduction  may  be  drawn  from  the  fact  that  since 
1875  two  methods  of  treatment  were  pursued  at  the  different  sta- 
tions of  this  hospital.  In  Station  I.  the  combined  method,  consisting 
of  baths  at  the  temperature  of  the  room,  with  three  or  four  grams  of 
quinine  daily,  and  sodium  salicylate  was  practised;  in  Station  II.  the 
methodical  Brand  bath  of  60°  to  65°  F.,  for  fifteen  minutes  whenever 
the  temperature  reached  103°  F.,  no  medicine  being  used.  The  bar- 
racks in  which  this  treatment  was  executed  are  so  well  ventilated,  as  I 
have  observed  from  personal  inspection,  that  their  temperature  in  winter 
averages  about  45°.  The  long  room  is  heated  by  iron  stoves,  is  open 


THE   FULL   BATH. 


209 


near  the  roof,  and  is  so  well  supplied  with  windows  that  it  resembles 
a  florist's  hot  house.  Two  tubs,  of  ordinary  zinc,  stand  at  its  upper 
end,  under  the  faucet,  and  to  these  the  patients  are  carried.  Such 
management  seems  heroic  indeed,  but  the  results  are  astounding : 


Results. 

Combined 
Treatment. 

Strict  Baths. 

Number  of  cases  

667 

221 

Mortality  

7.  6  per  cent. 

2.  7  per  cent. 

Average  stay  in  hospital  

40.  7  days 

47  3  days 

Average  duration  of  fever  

1.9  week. 

1.8  week. 

Percentage  of  complications  

82 

652 

Average   number  of  diarrhoeas  a  day  and 
person. 

1.9 

0.7 

The  reports  of  Vogl  are  altogether  a  most  remarkable  therapeutic 
statement,  because  they  offer  unimpeachable  testimony  to  the  effect 
upon  the  same  type  of  patients  (soldiers  of  about  the  same  average 
age  and  condition  of  previous  health)  under  depleting,  expectant, 
and  water  treatment,  and  also  striking  evidence  on  the  difference 
between  a  combined  water  and  medicinal  (antipyretic)  method  and  the 
systematic  Brand  (antifebrile)  method,  and  a  modified  Brand  method 
with  colder  water.  The  numbers  are  sufficiently  large  to  entitle  them 
to  respect,  and  the  long  period  of  time  during  which  these  observations 
have  been  made  by  various  independently  acting  medical  officers  must 
exclude  all  possible  errors  resulting  either  from  personal  bias  or  varia- 
tions in  the  type  of  the  disease.  These  statistics  are  therefore  the 
most  unimpeachable  existing  in  medical  history. 

Effect  on  Nutrition. — Vogl  has  confirmed  the  important  fact,  first 
brought  out  prominently  by  Brand,  that  the  capacity  for  enjoying  and 
digesting  semisolid  food  is  greatly  enhanced  by  the  cold-bath  treatment. 
Drs.  George  Peabody  and  Austin  Flint  have  made  the  same  observation 
in  Belle vue  Hospital.  The  former  even  allows  solid  food  in  the  third 
week  of  the  fever,  and  the  latter  has  informed  me  that  the  appetites 
of  his  patients  are  difficult  to  appease  after  using  the  bath  treatment. 
How  different  the  condition  of  the  stomach  is  under  the  expectant  or 
antipyretic  treatment  every  experienced  physician  knows  but  too  well. 
As  Brand  graphically  says,  and  I  can  confirm  from  personal  observa- 
tion :  "  While  under  the  water  treatment  the  tongue  is  moist,  pale, 
without  fur ;  the  pharynx  is  free  from  pain ;  the  stomach  and  intestines 
are  free  from  catarrh,  the  latter  showing  only  swollen  glands,  we  find 
under  other  treatment  the  tongue  hard,  brown,  and  dry;  saliva 
absent;  swallowing  painful ;  stomach  and  bowels  utterly  incapable  of 
digesting,  their  mucous  lining  covered  with  ulcers;  the  bowels  dis- 
tended ; — and  in  this  condition  the  school  demands  that  the  patient  be 
14 


210        THE   PRINCIPLES  AND   PRACTICE   OF   HYDRO-THERAPY. 

well  nourished.  What  a  singular  demand !  The  digestive  organs  are 
in  so  nearly  a  normal  state  under  the  bath  treatment  that  I  often  ask 
myself  the  question  if  it  may  not  be  safe  to  give  more  solid  food,  in 
order  to  appease  the  hunger.  I  find  in  Virchoiv's  Archiv,  1889,  pages 
95  and  303,  an  essay  by  Hosslin,  who  demonstrates  that  even  in  fever 
and  diarrhoea,  so  long  as  these  do  not  reach  a  very  high  temperature, 
as  is  usual  in  typhoid  fever,  the  nutriment  is  almost  completely  taken 
up ;  that  there  is,  therefore,  no  reason  for  giving  fever  patients  less  food 
because  it  is  not  digested  and  absorbed.  He  regards  it  as  necessary  to 
offer  typhoid  patients  the  largest  possible  quantity  of  concentrated 
food,  as  milk,  meat,  eggs,  flour  preparations,  etc.,  all,  however,  in 
minced  or  liquefied  form." 

Tripier  and  Bouveret  give  bouillon,  extract  of  beef,  coffee  and  tea 
with  milk,  one-half  pint  after  each  bath.  During  the  time  of  relative 
apyrexia  they  allow  rolls,  rice,  cream,  tapioca,  chocolate,  four  soft 
eggs  daily,  etc.  As  soon  as  the  temperature  is  nearly  normal,  they 
allow  roast  chicken,  bread  and  milk,  lean  meat,  rice,  baked  brain, 
white  lean  meat,  a  little  boiled  beef,  finely  ground,  etc.  Vogl  gives 
from  the  first  day  coffee,  meat  broth  with  a  little  flour  and  eggs,  milk, 
one  bottle  of  red  wine  daily ;  later,  bouillon  and  eggs,  so  that  patients 
receive  daily  fifty  grams  albumin,  forty-five  grams  of  fat,  and  two 
hundred  grams  of  carbohydrates,  a  food  quantum  that  could  not  be 
permitted  to  patients  who  are  not  bathed.  Brand  says  the  most  im- 
portant element  of  nutrition,  besides  the  food,  is  a  good  stomach,  and 
that  this  may  be  obtained  by  the  systematic  bath  treatment. 

In  an  able  essay  by  Dr.  J.  H.  Musser  on  the  indications  for  the  use 
of  alcoholic  stimulants  in  typhoid  fever,*  the  following  well-founded 
statement  is  made :  "  Now  it  is  well  known  that  the  modern  methods 
of  treatment — namely,  the  use  of  water,  internally  and  externally — less- 
en or  mitigate  the  effects  of  the  toxaemia,  and  secondarily  the  exhaus- 
tion, to  a  far  greater  degree  than  any  form  of  treatment  thus  far  em- 
ployed. Any  hospital  steward  will  tell  us  that  less  money  is  spent  for 
alcohol  since  the  introduction  of  the  *  Brand  method '  than  before  it 
was  employed.  All  physicians  recognize  that  the  necessity  for  the  use 
of  stimulants  arises  less  frequently  than  formerly."  This  testimony 
from  an  experienced  clinician  and  teacher  confirms  the  observations 
of  the  author,  who  has  recently  treated  a  number  of  cases  in  private 
practice  without  any  stimulant.  If  the  Brand  bath  possessed  no  other 
merit,  this  evidence  of  its  sustaining  influence  upon  the  heart  would 
entitle  it  to  earnest  advocacy. 

The  bedside  observations  of  the  strict  bath  advocates  are  so  rich  in 
demonstrations  of  its  beneficial  effect  upon  all  the  functions  which  con- 

*  Therapeutic  Gazette,  April  15th,  1900. 


THE   FULL   BATH.  211 

tribute  to  the  maintenance  of  strength  and  endurance  during  fever 
that  I  would  fain  cite  them,  did  space  permit. 

I  have  endeavored  to  show  as  briefly  as  possible  the  reasons  the 
results  are  more  favorable  under  the  cold-bath  treatment  first  suggested 
by  Brand  in  1861.  The  latter  is  thus  demonstrated  to  be  the  ideal 
treatment  for  typhoid  fever,  and  whenever  a  departure  is  made  from 
it  Jiirgensen's  opinion,  given  at  the  congress  in  London,  is  sustained. 
He  said  that  "whenever  he  attempted  to  deviate  from  the  rigorous 
cold-water  treatment,  he  was  compelled  to  return  to  it,  in  order  to  ob- 
tain the  best  results." 

Personal  Experience  of  Physicians. — Dr.  W.  G.  Thompson  con- 
firms the  testimony  of  Ziemssen  and  Vogl,  derived  from  personal 
experience,  of  the  beneficial  effect  of  cold  baths  upon  themselves 
when  they  had  suffered  from  typhoid  fever.  Vogl  and  Thompson  say 
that  they  should  not  be  deterred  by  the  protests  of  the  patient  from 
rigorously  executing  the  plan  of  three-hourly  bathing  so  long  as  the 
temperature  is  103°  in  the  rectum,  or  when  the  sensorium  is  deeply 
depressed  even  with  a  lower  temperature.  "  Even  sleep  should  not 
prevent  resort  to  the  thermometer  and  bath,  if  temperature  and  pulse 
urgently  demand  it." 

Aim  of  the  Cold  Bath. — The  object  of  this  treatment,  it  must  be 
finally  understood,  is  not  to  subdue  the  temperature,  but  to  refresh  and 
energize  the  vital  organs,  and  thus  insure  a  vigorous  resistance  to  the 
toxic  influences  arising  from  the  infective  processes.  This  is  the  great 
aim  to  be  kept  steadily  before  us;  it  is  clear  and  evident  from  the 
rationale  of  its  action.  The  latter  has  been  entered  into  with  some 
detail  (pages  174-187)  in  order  to  carry  conviction  to  those  minds 
which  are  prejudiced  sufficiently  not  to  be  satisfied  with  the  empirical 
demonstration  afforded  above.  The  searcher  after  truth  justly  de- 
mands a  reasonable  explanation  of  the  action  of  a  therapeutic  agent 
before  admitting  the  latter  to  his  confidence  when  the  issues  are  so 
vital. 

OBJECTIONS  URGED  AGAIXST  THE  BRAXD  METHOD. 

Many  objections  to  the  strict  execution  of  Brand's  method  have 
been  urged.  Some  of  these  are  too  puerile  to  require  notice;  others 
are  so  absurd  and  unphysiological  that  their  inconsistency  with  the 
known  principles  of  heat  regulation  needs  but  to  be  pointed  out. 

Objection  I.  This  is  an  example  of  the  ad  captandum  objections 
sometimes  found  in  our  literature :  The  editor  of  a  popiilar  medical 
journal,  who  does  not  believe  in  cold  bathing  in  typhoid  fever,  therein 
agreeing  with  many  other  physicians,  does  not  hesitate  to  give  expres- 


212        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

sion  to  his  disbelief  as  follows :  "  If  the  fact  that  a  typhoid  patient  is 
too  hot  is  sufficient  cause  for  sousing  him  in  cold  Avater,  \vhy  shall 
we  not  also  relieve  a  starving  man  by  a  liberal  alloAvance  of  food,  and 
revive  a  man  dying  of  thirst  by  unlimited  amount  of  water  internally? 
'Look  at  the  increased  renal  elimination,'  triumphantly  shouts  the  im- 
mersionist,  who  uses  the  bath  not  to  reduce  temperature,  but  to  im- 
prove phagocytosis  and  nutrition.  He  overlooks  the  fact  that  this 
treatment  checks  perspiration,  drives  the  blood  from  the  skin  to  the 
already  congested  and  poisoned  viscera,  and  leaves  only  the  choice 
between  diuresis,  diarrhoea,  and  death.  The  immersionists  plunge 
almost  every  case  of  typhoid  that  comes  into  their  wards,  including 
anaemic  girls,  flabby  Avomen,  debilitated  men,  for  whom  cold  bathing 
should  be  prescribed  with  the  greatest  caution  (not  more  than  twice 
daily),  if  they  sought  advice  for  the  general  conditions  of  weakness 
uncomplicated  by  typhoid." 

The  Avell-informed  physician  need  not  be  reminded  that  pa- 
tients are  not  soused  in  cold  water  because  they  are  too  hot ;  that  the 
increased  renal  elimination  is  not  due  to  "  driving  the  blood  from  the 
skin  to  the  already  congested  and  poisoned  viscera;"  that  the  effect  of 
the  Brand  bath  is  really  to  congest  the  skin,  as  shown  by  the  redness 
produced,  and  thus  to  unload  the  congested  viscera;  that  the  kidneys 
are  stimulated  to  increased  "  elimination  of  poisons"  through  improved 
cardiac  action.  Whoever  has  bathed  "  anaemic  girls"  and  "  flabby  wom- 
en" for  typhoid  knows  that  most  of  them  react  well  under  properly 
administered  baths,  and  that  their  power  of  resistance  is  enhanced  by 
them,  if  carefully  adapted. 

Objection  II.  Being  educated  to  regard  the  expectant  plan  of  treat- 
ment as  the  best,  many  physicians  are  loath  to  abandon  the  policy  of 
expectancy,  whose  aim  it  is  to  allow  the  fever  to  pursue  its  own 
course.  The  annoyance  involved  in  the  bath  is  not  in  accordance  with 
the  expectant  plan,  whose  object  it  is  to  avoid  all  disturbance  of  the 
patient  for  remedial  purposes.  Others  reserve  the  bath  for  severe  cases. 
As  long  as  AVB  had  only  an  inefficient,  if  not  injurious,  medicinal 
treatment,  it  Avas  Avise  to  avoid  disturbing  sleep.  ,But  in  a  severe 
case  of  typhoid  fever  it  is  as  important  to  disturb  sleep,  if  due  to 
stupor,  as  it  is  in  opium  poisoning  Avhen  stupor  supervenes.  In- 
deed, the  treatment  is  somewhat  analogous,  inasmuch  as  the  object  is 
chiefly  to  arouse  the  nerve-centres  and  keep  them'aroused  (though  not 
continuously,  as  in  the  latter)  until  the  toxaemia  has  passed  aAvay. 
The  most  experienced  clinician  is  unable  to  predict  in  the  initial  stage 
of  typhoid  fever  the  probable  intensity  of  its  course.  It  is  therefore 
incumbent  upon  the  practitioner  .to  initiate  the  friction  bath  early,  be- 
cause reliable  reports  have  proven  its  value  as  a  prophylactic,  Avhich 


THE   FULL  BATH.  213 

renders  the  course  of  the  disease  mild  by  preventing  the  serious  and 
often  fatal  complications. 

Objection  III.  The  apparently  heroic  character  of  the  Brand  method 
may  intimidate  physicians  into  the  preference  of  antipyretics  in  a 
guarded  form.  The  idea  that  the  reduction  of  temperature  is  the 
leading  object  of  the  cold  bath,  and  the  much  greater  facility  of  accom- 
plishing this  object  by  antipyrin  and  antifebrin,  may  deter  many  from 
adopting  the  former.  The  fallacy  of  this  course  has  been  demonstrated; 
it  is  happily  not  so  prevalent  at  the  present  time  as  formerly. 

Timid  persons  maybe  alarmed  by  the  patient's  pallor,  small  pulse, 
and  complaints  of  chilliness  while  in  the  cold  bath.  But,  if  it  is  prop- 
erly administered,  with  chafing  of  the  body  and  limbs,  these  effects 
will  be  counteracted  to  some  extent.  Reaction  after  removal  will  soon 
reassure  the  attendant,  and  embolden  him  to  order  regular  repetition. 

Objection  IV.  A  careless  application  of  the  bath,  or  the  substitu- 
tion of  some  other  method — packing,  sponging,  sprinkling,  etc. — will 
fail  and  cause  discouragement.  These  are  not  cold  bathing.  They 
are  useful,  however,  when  the  strict  method  is  impossible. 

The  only  modification  of  the  general  cold  bath  advised  by  Brand 
when  the  temperature  reaches  103°  is  the  stimulating  affusion  in  cases 
threatening  heart  failure  and  delirium.  This  is  a  warm  half-bath, 
with  affusions  of  50°  to  60°  over  the  head,  chest,  and  back.  (One  im- 
portant point  is  that  the  tub  should  always  be  brought  to  the  bedside 
to  avoid  unnecessary  disturbance  of  the  patient.) 

Objection  V.  Limited  experience.  A  small  experience,  personal 
or  from  hearsay,  which  may  have  been  unfavorable  in  one,  two,  or  sev- 
eral cases,  will  deter  some  from  adopting  the  energetic  cold  bathing. 
The  average  experience  with  cold  bathing  in  England,  where  it  has 
not  found  much  favor,  has  been  too  small  to  afford  a  proper  estimate 
of  its  value.  Dr.  Bristowe,  of  St.  Thomas'  Hospital,  may  be  cited  as 
an  example.  He  says:  "My  personal  experience  in  this  treatment  is 
not  extensive,  and  for  some  years  I  have  rarely,  if  ever,  resorted  to  it. 
I  have  undoubtedly  seen  patients  apparently  benefited  and  making  a 
good  recovery,  but  I  have  never  felt  satisfied  that  the  benefit  was 
real." 

During  a  visit  to  one  of  the  largest  London  hospitals  in  1896,  the 
visiting  physician  astonished  the  writer  by  replying  to  the  question 
what  he  thought  of  the  cold-bath  treatment  of  typhoid  fever,  that  he 
regarded  it  as  too  heroic  and  preferred  the  expectant  plan. 

Our  English  confreres  had  evidently  not  grasped  Brand's  idea 
at  that  time,  else  their  large  material  would  have  surely  enabled  them 
to  see  practical  demonstrations  of  its  enormous  superiority  over  the 
expectant  plan.  The  latter  is  correctly  named,  because  the  physician 


214        THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

pursuing  it  is  constantly  expecting  some  complications,  with  which 
he  finds  himself  but  too  often  impotent  to  cope. 

Dr.  Austin  Flint  published,  in  1882,  a  lecture  which  exercised  a 
potent  influence  in  this  country.  He  treated  seventeen  cases  in 
Bellevue  Hospital.  "  In  a  few  cases  the  cold  bath  of  80°  F.,  gradually 
reduced  to  65°,  was  employed,  but  was  discontinued  on  account  of  in- 
convenience." His  conclusion  was  that  the  antipyretic  treatment 
neither  increased  nor  diminished  the  mortality,  which  was  four  out  of 
the  seventeen  cases.  His  son,  who  was  the  first  physician  in  this 
country  to  'follow  me  in  adopting  the  strict  Brand  method,  after  ob- 
taining my  personal  suggestions  on  the  proper  method  of  the  strict 
Brand  bath,  pursued  it  with  success  in  the  same  wards  in  which  his 
great  father  abandoned  it. 

If  we  compare  these  meagre  statistics  with  those  offered  by  Brand 
and  the  recent  American  and  Australian  figures,  their  utter  insignifi- 
cance for  purposes  of  deduction  becomes  apparent. 

The  true  clinical  value  of  the  cold-bath  treatment  is  now  dwelt 
upon  in  many  text-books.  Strumpell,  who  has  a  large  experience, 
says,  with  his  usual  fairness:  "There  is  at  present  no  other  single 
method  of  treating  typhoid  fever  which  has  so  numerous  and  evident 
advantages  for  the  patient.  We  regard  it  as  a  duty  of  every  physi- 
cian who  undertakes  to  treat  a  severe  case  of  typhoid  fever  to  try  his 
best  to  have  the  bath  employed." 

Objection  VI.  The  difficulty,  if  not  impossibility,  of  treating  pa- 
tients before  the  fifth  day.  Indeed,  this  can  be  done,  it  is  claimed, 
only  in  military  hospitals  or  in  epidemics,  when  every  suspicious  case 
may  be  subjected  to  the  bath.  It  has  been  objected  that  "this  is  a 
very  delicate  adjustment  of  treatment  when  a  patient  is  saved  or  doomed, 
according  as  it  is  inaugurated  on  the  fourth  or  fifth  day."  This  is 
an  error.  While  one  day's  delay  may  be  of  little  consequence,  a  delay 
of  several  days  may  be  of  serious  import.  This  condition  applies  with 
equal  force  to  much  of  our  therapeutic  endeavor.  Principiis  obsta  is 
the  first  principle  of  rational  therapeutics.  Disease  may  properly  be 
likened  to  a  conflagration :  the  ease  of  its  subdual  is  in  proportion  to 
the  stage  at  which  it  is  attacked.  In  the  severe  types  of  malarial 
fever  which  I  have  seen  in  the  South,  for  instance,  one  day's — yes, 
even  one  hour's — cinchonization  may  save  the  patient's  life;  its  delay 
may  doom  him  to  death  or  to  long-continued  invalidism.  Brand  has 
demonstrated  as  clearly  as  anything  can  be  demonstrated  by  clinical 
data,  not  from  his  own  practice  only,  but  from  that  of  others  also, 
that  out  of  twelve  hundred  cases  treated  before  the  fifth  day  not  one 
was  fatal. 

The  uncertainty  of  diagnosis  here  steps  in  to  mar  possible  success. 
Before  the  appearance  of  the  spots,  we  cannot  pronounce  definitely 


THE   FULL   BATH.  215 

whether  we  have  a  case  of  typhoid  fever,  acute  tuberculosis,  gas- 
tric fever,  pneumonia,  acute  nephritis,  or  one  of  the  exanthemata. 
We  have  the  satisfaction  of  realizing,  however,  that  in  the  large  pro- 
portion of  cases  these  diseases  may  readily  be  excluded.  But  we  may 
easily  escape  from  the  dilemma  entirely  if  we  adopt  the  rule  to  subject 
every  case  of  fever  whose  temperature  persistently  marks  above  103°  for 
several  hours  to  ten  minutes  friction  baths  in  a  mild  form,  reducing  their 
temperature  'from  90°,  at  every  bath  five  degrees,  until  70°  have  been 
reached.  Experience  has  taught  me  that  no  harm  will  ensue  from 
such  a  course,  while  much  may  be  gained  by  thus  early  inaugurating 
the  battle  against  the  toxic  manifestations. 

Moreover,  these  baths  may  aid  us  in  reaching  a  diagnosis.  In 
my  hospital  service  I  have  directed  the  house  staff  to  bathe  at  once, 
and  "I  have  by  this  means  been  enabled  to  exclude  pneumonia,  acute 
tuberculosis,  osteomyelitis,  and  ordinary  remittents.  If  the  case 
proved  not  to  be  typhoid,  no  harm  was  done.  The  more  nearly  we 
approach  the  high,  standard  of  strict  bathing,  the  more  nearly  may  ^l•e 
approach  the  low  mortality.  The  earlier  the  baths  are  resorted  to,  the 
more  strictly  they  are  used  in  accordance  with  the  directions  regard- 
ing their  temperature  and  frequency,  the  more  completely  will  the  toxic 
processes  be  controlled  and  the  mortality  be  reduced. 

In  private  practice  the  early  preparatory  bath  is  useful  in  allaying 
the  anxiety  of  the  physician,  who  is  daily  importuned  for  a  diagnosis. 

Objection  VII.  Should  every  case  of  typhoid  fever  reaching  a  rectal 
temperature  of  103°  be  subjected  to  the  bath?  One  of  my  correspon- 
dents asks :  "  If  a  patient  has  a  temperature  of  104°  for  an  hour  or 
two  every  evening,  but  moderate  fever  for  the  rest  of  the  time,  and 
without  'Functionsstorung,'  should  you  then  think  it  necessary  to  insist 
upon  the  bath?"  This  is  a  question  that  will  frequently  arise  in  the 
mind  of  the  practitioner,  who  would  fain  shrink  from  the  trouble,  an- 
noyance, and  possible  criticism  of  the  bath  procedures  so  long  as  the 
case  presents  a  mild  aspect.  It  will  not  be  difficult  for  the  attendant 
to  order  and  insist  upon  the  cold  bath,  if  the  patient  has  a  temperature 
of  105°,  with  delirium,  stupor,  etc. ;  but  when  he  appears  to  be  com- 
fortable, with  a  temperature  ranging  between  102°  and  103°  or  104°, 
it  does  seem  so  glaring  a  violation  of  the  long-established  expectant 
treatment  to  disturb  his  comfort  by  a  cold  bath  that  few  men  will 
have  the  temerity  to  advise  it. 

It  is  a  wise  practice  to  bathe  under  these  conditions.  The  ex- 
perienced practitioner  knows  but  too  well  how  sadly  his  prognosis, 
derived  from  an  early  mild  course,  sometimes  fails  to  be  verified, 
when,  in  the  beginning  of  the  third  week,  the  first  sound  of  the  heart 
begins  to  fail,  the  pulse  becomes  rapid,  the  lung  becomes  hypostatic, 
hemorrhage  and  perforation  ensue,  and  death  closes  the  scene. 


216       THE  PRINCIPLES  AND  PRACTICE  OF  HYDRO-THERAPY. 

A  death  from  typhoid  in  the  first  week  from  excessive  tempera- 
ture or  from  failure  of  the  nervous  system  is  rarely  observed ;  the  chief 
danger  lies  in  the  infective  process,  which  undermines  the  system 
slowly  but  surely.  To  meet  this  danger,  the  cold  bath  is  our  shield 
and  ever-ready  weapon.  In  mild  cases,  the  rise  of  temperature  and 
pulse  is  readily  combated  by  it,  the  resisting  power  of  the  disease 
being  feeble.  Hence  the  temperature  rises  only  at  long  intervals  to 
103°  F.,  but,  whenever  it  does  so  rise,  the  rule  should  be  inexorable: 
the  bath  must  be  administered.  Clinical  experience  demands  it,  and 
if  we  would  receive  its  benefits  we  must  obey  the  behest. 

Objection  VIII.  Difficulty  of  execiiting  the  Brand  method  in  pri- 
vate practice.  Despite  the  reiterated  statements  of  Brand,  Sihler, 
Tripier  and  Bouveret,  and  of  the  author,  this  objection  is  again  and 
again  urged  in  our  medical  societies.  Brand  has  told  us  how  a  poor 
printer's  apprentice  boy  was  carried  through  a  case  of  typhoid  by  his 
sister  and  brother,  ten  and  thirteen  years  old,  under  his  personal 
supervision.  Carl  Sihler  has  graphically  described*  how,  in  a  practice 
among  artisans  and  laboring  people,  he  has  carried  over  one  hundred 
cases  of  typhoid  fever  to  a  successful  issue,  some  of  them  receiving 
over  ninety  baths  from  relatives  and  friends. 

"  In  the  case  of  a  widow  with  a  string  of  children  from  two  years 
upward  there  was  no  money  for  a  nurse,  and  a  married  sister  who 
acted  as  nurse  was  very  timid.  Sihler  sent  one  of  his  nurses  to  the 
house,  and  after  six  baths  had  been  given  the  necessary  fortitude  and 
skill  for  patient  and  sister  were  obtained,  and  everything  went  ahead 
smoothly  and  much  to  the  satisfaction  of  all  concerned." 

This  picture  from  life  may  prove  instructive  and  incite  emulation. 
Even  in  rural  districts  the  bath  method  may  be  carried  out  with  fair 
success.  When  practising  medicine  in  Camden,  South  Carolina,  in  the 
seventies  the  author  was  in  the  habit  of  sending  a  wooden  tub  lined 
with  tin  to  the  farmhouses  in  which  typhoid  fever  prevailed.  It  was 
his  practice  to  visit  these  cases  in  the  evening,  the  distance  being  some- 
times ten  miles,  and  remaining  over  night,  in  order  to  instruct  in  and 
watch  the  treatment. 

From  distant  Australia  we  have  an  example  of  what  may  be  ac- 
complished by  energy,  perseverance,  and  faith.  Murtra  reports  in  the 
Miinchener  medicinische  Wochenschrift,  Nos.  47  and  48,  1895,  one 
hundred  and  seventy-three  cases  of  typhoid  fever  treated  by  the  strict 
Brand  bath  in  a  sparsely  settled  rural  distirct  under  the  most  adverse 
conditions.  The  mortality  was  only  5.4.  Such  a  result  must  serve  as 
a  rebuke  to  the  city  doctor  who  has  nurses,  consultants,  and  often  the 
comforts  and  agencies  of  modern  life  at  his  disposal. 

I  have  not  infrequently  encountered  serious  opposition  from  rnein- 
*  Journal  of  the  American  Medical  Association,  July  22d,  1889. 


THE   FULL   BATH.  217 

bers  of  the  family.  My  method  of  overcoming  this  is  very  simple. 
The  family  is  informed  that  a  large  proportion  of  typhoid-fever  cases 
recover  under  the  usual  treatment,  and  that  such  a  result  may  be  antici- 
pated with  probability  in  the  case;  'but  that  under  the  cold-bath  treat- 
ment, adopted  early,  recovery  is  certain.  Thus  the  choice  is  left  to  the 
head  of  the  family,  who  usually  elects  to  place  the  responsibility  on  the 
physician. 

Dr.  Barker,*  of  St.  Louis  "  has  not  found  the  consent  of  the  family 
so  difficult  to  obtain  as  some  would  have  us  suppose.  To  overcome 
this  prejudice,  he  sends  some  missionary  literature  or  sends  the  friends 
of  the  patient  to  some  family  in  which  the  bath  has  been  successfully 
used.  After  a  few  baths  no  argument  is  needed.  He  begins  with  a 
temperature  of  90°,  to  secure  confidence,  and  gradually  lowers  it." 

Dr.  A.  B.  Ball,  of  this  city,  declines  to  treat  the  case  if  he  is  not 
permitted  to  bathe. 

The  nurse  who  has  watched  and  cared  for  a  case  of  typhoid  with 
delirium,  stupor,  involuntary  defecation,  and  urination  will  gladly 
accept  the  toil  and  worry  of  the  bath  treatment  as  less  trying.  The 
relative  or  friend  who  has  been  alarmed  by  these  manifestations  will 
joyfully  recognize  the  different  aspect  of  the  case  under  the  cold-bath 
treatment.  Such  individuals  will  not  require  to  be  stimulated  to  the 
energetic  execution  of  the  baths ;  they  will  become  ardent  advocates. 
Thus  prejudice  will  be  dissipated. 

Objection  IX.  Shock.  One  of  the  most  frequently  urged  objections 
to  the  cold  bath  is  the  "  shock"  this  "  heroic"  procedure  may  inflict  upon 
the  heart.  The  fallacy  of  this  idea  cannot  be  more  logically  met  than 
with  the  hundreds  of  case  records  in  the  New  York,  Presbyterian,  Man- 
hattan General,  and  other  hospitals  of  this  city. 

When  suggesting  the  cold  baths  in  consultation  I  am  not  infre- 
quently met  by  objection  on  account  of  the  patient's  feeble  pulse. 
The  following  table  (page  218)  giving  the  summary  of  a  case  of  typhoid 
shows  that  without  stimulants,  which  could  not  be  retained,  a  heart 
beating  130  to  140,  with  a  temperature  of  104°  to  105.6°  F.,  was  kept 
in  good  condition,  being  reduced  to  116  or  120  by  baths  of  76°  for  twenty 
minutes  with  friction.  Such  records  are  the  best  reply  to  the  ob- 
jection that  cold  baths  are  contraindicated  in  heart  feebleness.  This 
patient  became  cyanotic  whenever  the  bath  temperature  was  below  76° 
F.,  and  yet  she  had  practically  no  stimulants,  because  she  vomited  them. 

As  germane  to  this  point  it  may  be  of  interest  to  quote  from  a  brief 
report  in  the  Medical  Record,  November  7th,  1896,  of  a  discussion  on 
the  subject,  the  following:  "Dr.  Simon  Baruch  upheld  the  Brand 
treatment  and  pointed  to  the  charts  shown  by  Dr.  Thompson  as  proof 
that  the  bath  was  the  best  heart  tonic.  The  temperature  fell  and  th« 
*  Therapeutic  Gazette,  1894. 


218       THE   PRINCIPLES   AND   PRACTICE   OF    HYDROTHERAPY. 


heart's  action  always  became  slower  and  stronger.  Further,  the  bath 
was  eliminative,  for  the  urinary  secretion  was  increased  and  with  it 
the  poisons  in  the  circulation.  The  great  bugbear  was  shock,  and  re- 
action was  wanted  for  its  stimulating  effect.  Dr.  Thompson  confirmed 
the  statements  made  by  Dr.  Baruch  in  response  to  Dr.  Dudley's  asser- 
tion that  the  bath  was  not  eliminative  and  was  weakening  to  the 
heart." 

Objection  X.  Danger  of  colds  and  lung  troubles.  The  possibility 
of  these  being  induced  by  the  cold  bath  is  still  a  superstition  in  the 
lay  mind  which,  unhappily,  has  not  yet  been  entirely  removed  from  the 

TWENTY-FOUR  HOURS'  RECORD  OF  CASE  OP  MRS.  G ,  AGED  40. 


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medical  mind.  This  objection  has  also  been  abundantly  answered  by 
clinical  demonstrations.  I  have  never  seen  more  "  cold-threatening" 
conditions  than  exist  in  the  military  hospital  of  Vogl,  in  Munich.  If  a 
combination  of  cold  air  and  very  cold  baths  do  not  produce  bronchitis, 
pneumonia,  and  pleurisy  in  typhoid  fever,  the  bath  alone  may  be  re- 
garded as  free  from  such  accusation.  "  The  fear  of  cold  from  the  baths 
or  cold  air  in  typhoid  fever  is  unfounded, "  says  Vogl. 

On  the  contrary,  so  far  from  producing  lung  complications,  the 
numerous  cases  detailed  in  extenso  by  Brand,  Vogl,  Tripier  and 
Bouveret,  and  others  go  to  prove  that  we  have  in  the  cold  bath  the 


THE      FULL   BATH.  219 

most  effective  treatment  against  pulmonary  complications,  when  they 
occur  during  typhoid  fever;  only  when  these  occur  in  far-advanced 
stages  of  the  fever,  with  great  adynamia,  the  cold  bath  should  be  ex- 
changed for  that  of  a  milder  temperature  and  more  brief  duration. 

Objection  XI.  The  exacting  technique  of  the  Brand  method  de- 
mands the  subjection  of  the  physician's  judgment  to  a  routine  rule. 
The  question  has  been  asked :  "  Is  the  rule  to  bathe  every  three  hours 
in  winter,  at  65°  F.,  whenever  the  temperature  reaches  103°  F.,  ab- 
solute, and  not  to  be  modified  to  adapt  it  to  each  case?" 

I  should  rarely  deviate  from  the  rule,  except  in  the  beginning,  when 
the  patient's  peculiarities  may  be  noted;  because  this  rule  has  been  es- 
tablished by  deduction  from  large  clinical  material,  carefully  gathered 
by  numerous  observers  in  different  localities,  in  private,  hospital,  and 
military  practice.  Until  the  physician  has,  by  his  own  observations, 
discovered  a  more  effective  mode  of  treatment,  he  would  do  well  to  fol- 
low Brand's  rule.  Prejudice  against  this  method  should  not  weigh 
against  the  accumulated  observations  of  reliable  practitioners.  This 
would  be  only  fair  to  the  patient.  It  must  always  be  borne  in  mind, 
too,  that  the  object  of  the  bath  is  prophylactic;  its  aim  is  not  a  mere 
reduction  of  temperature,  but  a  suppression  of  the  violence  of  the  fe- 
brile movement  until  it  has  spent  its  force.  Whoever  expects  to  throt- 
tle the  fever  by  the  bath  will  surely  be  disappointed,  for  its  course  is 
as  steady  and  inexorable  as  is  any  law  of  nature.  The  temperature 
will  almost  invariably  fall  one  or  two  degrees  after  each  bath,  only, 
however,  to  rise  again  to  within  a  fraction  of  its  former  rate  when 
three-hourly  examination  is  made.  But  from  day  to  day  there  will  be 
a  gradual  yet  steady  diminution  of  the  average  temperature,  which 
indicates  that  the  resisting-power  of  the  system  is  gaining  sway 
over  the  disease.  This  is  the  usual  effect  of  the  systematic  cold  bath, 
administered  without  fear  and  without  favor,  but  it  is  not  to  be  ex- 
pected from  modifications  of  the  Brand  bath.  Whenever  we  attempt 
to  substitute  another  form  of  hydriatric  procedure,  to  raise  the  temper- 
ature of  the  bath  water,  to  shorten  the  duration  of  the  bath,  or  other- 
wise to  change  the  rule,  we  must  expect  a  change  in  the  result.  *  If 
the  case  comes  under  treatment  late,  the  resisting-power  of  the  disease 
will  be  greater ;  hence  the  result  of  the  bath  will  deviate  from  that 
here  depicted.  The  type  of  severity  of  the  disease,  too,  may  also  mod- 
ify the  bath. 

Care  should  be  taken  that  the  opposite  error  of  reducing  the  bath 
temperature  below  the  Brand  rule  be  not  committed.  This  may  be 
illustrated  by  a  recent  report!  of  Vogl,  describing  an  epidemic  in  1893. 

*  "  The  closer  the  method  has  been  followed,  the  better  the  reports  seem  to 
be.— (Editorial,  Medical  Record.  May  7,  1898). 

f  Miinchener  medicinischo  Wochenschrift,  No.  40,  1895. 


220       THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

Although  this  treatment  is  claimed  as  a  strict  (?)  Brand  method,  the 
results  were  not  so  favorable  as  in  previous  reports,  for  the  following 
reasons,  which,  in  iny  opinion,  offer  some  valuable  lessons.  He  writes : 

"  The  number  of  cases  admitted  to  the  garrison  hospital  was  four 
hundred  and  twenty-six;  the  number  of  deaths  thirty-six — 8.4  per 
cent  mortalitj'.  An  epidemic  of  influenza  had  preceded  the  typhoid 
epidemic  and  was  still  prevailing  to  such  an  extent  that  most  of  the 
soldiers  suffered  from  a  combination  of  these  toxic  agencies.  As  a 
result  there  existed  a  tendency  to  hemorrhage  which,  in  its  extent, 
was  unusual,  and  an  involvement  of  the  central  nervous  system  which 
was  more  pronounced  than  had  been  observed  in  any  previous  epidemic. 
A  toxic  affection  of  the  cardiac  ganglia  which  produced  great  slowing 
and  asthenia  of  the  pulse  seemed  to  be  prevalent.  All  these  seemed 
to  diminish  the  resisting-capacity  of  the  patients  in  this  epidemic,  and 
doubtless  account  for  its  fatality  despite  the  adoption  of  the  Brand  [?] 
method,  which  consisted  of  the  regular  administration  of  baths  at 
12  R.  (59°  F.)  for  fifteen  minutes  every  three  hours  whenever  the  pa- 
tient's temperature  reached  102°  F.  in  the  rectum,  accompanied  by  a 
daily  bottle  of  red  wine,  strong  black  tea  with  cognac  after  each  bath, 
soft-boiled  eggs,  flour-and-egg  soup,  one  and  one-half  to  two  and  one- 
half  quarts  of  milk.  Ten  thousand  baths  were  administered  during 
this  epidemic." 

Although  Dr.  Vogl  is  satisfied  with  the  mortality  of  8.4  per  cent, 
because  of  the  serious  type  of  this  epidemic,  this  result  compares  un- 
favorably with  his  previous  results,  which  never  exceeded  5.2  per 
cent  in  any  one  year  and  averaged  2. 7  per  cent.  Vogl  finds  the  expla- 
nation of  this  unwonted  fatality  (which  is  much  less  than  is  usual  un- 
der non-hydriatric  management)  in  the  coexistence  of  influenza,  which 
in  the  initial  stages  even  produced  great  irregularity  of  the  pulse,  etc., 
and  other  manifestations  of  cardiac  incompetency,  which  render  the 
treatment  by  bathing  ever  a  serious  problem.  Nevertheless,  the  bath 
treatment  furnished  evidence  of  the  invigorating  effects  of  the  baths, 
inasmuch  as  their  cessation  was  always  followed  by  failure  of  cardiac 
action  and  nerve  tone,  and  their  resumption  by  improvement,  dur- 
ing the  long  existence  (five  or  six  weeks)  of  the  infective  process. 

In  view  of  the  great  ability  of  Vogl  and  his  valued  labors  in  this 
field,  I  would  prefer  to  pass  this  remarkable  report  without  criticism, 
but,  from  my  standpoint,  the  bath  given  in  these  cases  was  not  strictly 
according  to  Brand.  A  bath  of  59°  F.,  six  degrees  below  the  mini- 
mum temperature  advised  by  Brand,  probably  demanded  a  greater 
response  on  the  part  of  the  weakened  heart  than  it  was  capable  of  ren- 
dering without  damage.  Be  it  understood  that  this  is  no  contradiction 
of  the  position  assumed  by  Brand,  and  so  often  confirmed  by  Dr. 
Vogl  himself  and  the  author,  that  the  cold  bath  is  the  best  heart 


THE   FULL   BATH.  221 

tonic  in  typhoid  fever.  The  reader  should  bear  in  mind  that  this 
tonic  effect  is  prophylactic  rather  than  direct,  and  that,  as  has 
been  emphasized  (page  220),  in  advanced  stages  of  cases  which  have 
not  had  the  benefit  of  early  bathing  the  baths  are  not  so  efficient,  and 
the  temperature  should  be  chosen  with  great  care.  The  patients  here 
reported,  began  with  hearts  already  enfeebled  by  toxaemia  from  in- 
fluenza, a  condition  almost  analogous  to  that  existing  in  the  third 
week  of  typhoid.  The  innervation  of  the  heart  was  unequal  to  re- 
spond to  the  demand  made  upon  it  by  very  cold  baths.  I  believe 
that  this  is  one  reason  why  the  latter  were  not  so  efficient  in  convert- 
ing the  severe  type  into  a  milder  form,  as  may  be  done  by  the  strict 
Brand  baths,  and  I  offer  it  as  illustrative  of  the  warning  that  when- 
ever we  deviate  from  the  exact  technique  of  Brand  our  results  will  also 
deviate  from  those  of  Brand.* 

Objection  XII.  Sentiment.  This  objection  may  be  found  not  only 
among  lay  people  but  also  among  some  physicians.  The  Medical 
Record,  of  November  18th,  1895,  contains  a  specimen  of  the  latter, 
which  perhaps  represents  the  sentimental  side  of  the  question.  This 
author's  horror  of  the  bath  treatment  is  really  affecting.  He  says: 
"  At  present,  bathing,  according  to  the  method  of  Brand,  is  enjoying 
an  enviable  popularity  as  a  method  of  reducing  temperature  and  pre- 
venting complications. 

"  Much  testimony  to  the  efficacy  has  been  presented,  bxit  rarely  has 
any  one  taken  the  pains  to  describe  in  print  the  piteous  and  ineffectual 
appeals  to  be  spared  the  distress  of  further  Brand  baths,  of  patients 
who,  in  spite  of  a  continuance  of  the  baths,  died.  Such  cases  never 
occupy  a  conspicuous  place  in  scientific  reports  of  the  modern  antipyretic 
treatment.  The  pathetic  side  of  the  story  never  appears  in  statistics." 

Such  an  "  argument, "  offered  in  lieu  of  statistics  or  clinical  data, 
scarce  requires  refutation.  But  as  such  innuendo  may  serve  to  intimi- 
date some  practitioners  in  whose  breasts  "  the  milk  of  human  kindness" 
abounds,  I  propose  to  analyze  its  merits. 

Dr.  J.  C.  Wilson,  f  Professor  of  Practice  in  the  Jefferson  Medical 
College,  says:  "As  a  rule  the  patients  did  not  object  to  the  baths; 
when  they  did  so,  the  objections  ceased  after  a  few  baths  had  been 
administered. " 

Dr.  W.  Gilman  Thompson  describes  his  personal  experience,  hav- 

*In  a  case  in  which  the  author  was  consulted  in  Chicago,  he  was  alarmed 
one  night  by  a  telephonic  message  that  the  patient  had  fallen  into  collapse 
after  a  bath.  Inquiry  elicited  the  fact  that  the  temperature  of  the  last  bath 
had  been  60°  F.  The  patient  recovered.  Errors  are  usually  committed  by 
those  who,  having  been  opposed  to  the  Brand  method,  have  been  converted 
by  observation  of  its  results. 

f  Medical  News,  December  6th,  1890. 


222        THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

ing  beeu  treated  by  cold  baths  for  an  attack  of  typhoid :  "  It  is  not 
agreeable,  at  any  time,  to  be  taken  out  of  a  warm  bed  and  suddenly 
immersed  in  cold  water,  but  the  after-effect  was  so  soothing  and  the 
favorable  influence  upon  all  the  symptoms  was  so  pronounced  that  the 
temporary  discomfort  was  easily  endured." 

The  pathetic  side  of  the  story  has  evidently  not  been  experienced 
by  these  careful  observers. 

The  same  writer  claims  that  the  Brand  bath  will  "  never  be  gener- 
ally adopted  in  rural  districts  and  in  private  practice  in  cities."  I  am 
satisfied  that  the  intelligence  of  the  community  will  force  even  reluc- 
tant and  sentimental  physicians  everywhere  to  save  the  lives  of  their 
dear  ones,  so  soon  as  they  become  well  informed  on  this  subject.  Al- 
ready the  lay  journals  have  taken  up  this  subject,  and  they  will  con- 
tinue to  probe  it.  In  our  large  cities  the  best  teachers  of  medicine  are 
converts  who  a  few  years  ago  were  sceptics.  When  men  like  Dela- 
field,  Draper,  and  Peabody,  teach  it  in  one  school,  and  Loomis  and 
Gilrnan  Thompson  in  another,  and  when  it  is  daily  practised  with  bril- 
liant results  in  the  New  York,  Roosevelt,  Presbyterian,  St.  Luke, 
Manhattan,  and  Austin  Flint's  and  Peabody' s  services  in  Bellevue 
Hospital,  the  bright  young  men  being  educated  at  these  schools  and 
hospitals  will  not  allow  sentiment  or  irrational  therapy  to  guide  them. 
There  is  need  of  more  positivism  in  medicine.  Between  two  positive 
methods  like  the  Brand  method  and  chemical  antipyretics,  it  did  not 
require  much  time  to  decide.  Intelligent  physicians  are  abandoning 
the  latter,  and  many  who  have  the  courage  of  their  convictions  are 
adopting  the  former  even  in  private  practice.  Dr.  A.  B.  Ball  informs 
me  that  he  has  encountered  no  serious  objection  in  private  practice, 
although  his  ultimatum  is  the  bath  or  a  change  of  attendants.  I  have 
treated  the  wife  of  a  physician  who  had  witnessed  similar  treatment 
of  another  patient  in  his  household ;  I  have  thus  treated  a  case  in  a 
fashionable  summer  hotel  without  trouble ;  I  have  treated  three  mem- 
bers of  the  same  family  by  baths  in  three  successive  years ;  and  I  have 
seen  the  same  tub  used  by  four  different  families,  each  obtaining  it 
from  the  other  at  my  suggestion.  "  Piteous  appeals"  did  not  deter 
even  these  lay  people  from  again  permitting  the  use  of  the  bath. 
Sentiment  and  pathos  must  yield  to  logic  and  common  sense,  in  medi- 
cine. 

At  the  meeting  of  the  British  Medical  Association  in  1896,  much 
opposition  to  the  cold  bath  in  typhoid  fever  was  manifested  on  senti- 
mental grounds,  which  were  met  by  Dr.  Osier,  who  stated  that  were 
the  treatment  even  more  heroic  and  unpleasant  he  would  not  hesitate 
to  adopt  it,  because  it  saves  lives  that  would  otherwise  be  sacrificed. 
This  testimony  from  a  man  who  said  three  years  previously*  that  "  the 
*  Johns  Hopkins  Hospital  Reports. 


THE   FULL,  BATH.  223 

results  of  the  treatment  have  been  so  excellent  as  almost  to  compel  its 
use  in  hospital  practice,  but  the  difficulties  attending  it  are  such  as  to 
render  its  use  in  private  practice  scarcely  feasible,"  is  more  convinc- 
ing, because  it  is  an  evidence  not  only  of  this  clinician's  well-known 
fairness,  but  of  the  effect  of  increased  experience  in  the  method. 

Objection  XIII.  Complications.  It  has  been  asserted  that  the  cold 
bath  increases  the  tendency  to  intestinal  hemorrhages  by  driving  the 
blood  from  the  periphery  to  the  enfeebled  intestinal  vessels.  Tripier 
and  Bouveret  met  only  four  cases  of  hemorrhage  among  two  hundred 
and  thirty -three  patients  treated  by  the  cold  bath ;  of  these  two  were 
fatal,  and  none  of  the  deaths  showed  any  connection  with  the  bath. 
They  conclude  that  their  own  experience  proves  that  intestinal  hemor- 
rhages are  less  frequent  under  hydriatric  management.  Brand,  who  has 
studied  every  phase  of  this  subject  with  an  eye  singly  to  the  eluci- 
dation of  the  truth,  has  sifted  the  histories  of  hundreds  of  cases  for 
this  purpose.  He  has  gathered  4,995  cases  of  typhoid  fever,  in  which 
155  hemorrhages  were  noted,  35  patients  dying  from  the  latter.  Hence 
the  frequency  is  3.1  per  cent,  and  the  mortality  0.6  per  cent.  On  the 
other  hand,  among  4,890  cases  not  treated  by  water,  he  discovered 
hemorrhages  271  times — 5.6  per  cent.  Goltdammer,  who  is  not  so 
warm  an  enthusiast  on  the  efficacy  of  strict  cold  baths  as  Brand,  fur- 
nishes larger  statistics  (nearly  20,000  cases),  from  which  he  con- 
cludes that  the  cold  bath  has  no  influence  in  producing  intestinal 
hemorrhages.  Vogl  noted  among  251  cases  treated  by  the  strict  cold 
bath  only  2  cases  of  bloody  stools.  In  a  recent  series  of  cases  the 
author  saw  one  case  of  hemorrhage  in  the  hospital,  during  the  Brand 
treatment,  and  one  in  private  practice,  in  which  the  friction  bath  was 
not  used  because  the  patient  never  reached  103°  in  recto.  The  former 
died  from  perforation  (having  been  admitted  ten  days  after  inception"), 
therefore  too  late  to  obtain  the  prophylactic  effect;  the  latter  recovered. 

All  evidence,  therefore,  tends  to  prove  that,  so  far  from  being  in- 
fluential in  the  production  of  hemorrhage,  the  cold  bath  actually  ren- 
ders it  less  rare  and  more  mild  and  tractable,  if  resorted  to  very  early 
in  the  disease,  and  the  reason  is  not  far  to  seek. 

"  That  the  alteration  in  Peyer's  glands  will  not  go  beyond  the  stage 
of  infiltration,  if  treatment  is  instituted  before  '  the  fateful  fifth  day,' 
is  another  prediction  that  raises  dubious  questionings,"  says  a  writer 
in  the  Medical  Record.  I  reiterate  the  reply  made  to  this  doubting 
Thomas,  because  it  is  a  doubt  which  is  but  the  legitimate  offspring  of  the 
experience  with  the  expectant  treatment  hitherto  in  vogue.  Fortunately 
for  the  patients,  but  unfortunately  for  our  pathological  enlightenment, 
the  opportunities  for  autopsy  are  exceedingly  rare  in  cases  treated  by  the 
strict  cold  bath.  Only  two  cases,  in  which  death  occurred  from  other 


224       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHEKAPY. 

causes,  but  which  had  been  bathed  before  the  fifth  day,  furnish  evi- 
dence on  this  point.  One  case  is  reported  in  Lyon  Medicate,  No.  14, 
1886,  and  another  by  Brand,  in  1883.  In  the  former,  the  patient  dying 
on  the  twenty -first  day  of  a  typical  typhoid,  there  was  found  no  loss  of 
substance,  old  or  new,  in  the  intestine.  In  the  latter,  also  fatal  on  the 
twenty-first  day,  there  were  no  ulceration,  no  cicatrix,  no  pigmented 
spots;  only  fresh  infiltration.  If  diarrhoea,  meteorism,  hemorrhage, 
and  a  dry,  red  tongue  are  indications  of  ulceration  of  the  intestinal 
glands,  the  absence  of  these  symptoms  in  the  large  proportion  of  cases 
treated  by  the  strict  cold  bath  must  be  accepted  as  logical  evidence  of 
the  absence  of  ulceration.  Vogl's  testimony  on  this  point  is  strikingly 
conclusive,  and  must  carry  conviction,  because  it  emanates  from  the 
comparative  experience  of  many  years  in  the  same  class  of  patients — 
soldiers.  He  says :  "  The  diminution  of  intestinal  symptoms  is  a  very 
evident  effect  of  the  cold  bath ;  a  few  trials  will  convince  any  one  of 
its  success.  Among  221  cases  there  was  a  daily  average  of  only  0.7 
per  cent  of  diarrhoeal  stools ;  while  in  the  cases  treated  with  a  com- 
bination of  baths  with  medicinal  antipyretics  the  average  was  1.9 
per  cent  of  diarrhoea.  Never  was  it  necessary  (in  251  cases  with  care- 
fully written  histories)  to  resort  to  opium  and  bismuth;  meteorism, 
with  tense  abdominal  walls,  was  observed  only  in  cases  received  late; 
it  was  diminished  by  the  baths."  If  inappropriate  diet  is  capable, 
as  we  know,  of  aggravating  the  intestinal  symptoms,  and  if  proper 
diet  is  capable  of  preventing  or  ameliorating  them,  is  it  unreasonable 
to  accept  the  proposition  that  the  bath  influences  favorably  the  local 
process,  which  is  but  one  of  the  manifestations  of  the  general  infection? 

When  intestinal  hemorrhage  is  severe  and  accompanied  by  general 
symptoms,  such  as  pallor,  small  pulse,  cold  extremities,  subnormal 
temperature,  the  bath  should  be  discontinued.  A  slight  discolora- 
tion of  the  stools  need  not  deter  the  attendant  from  continuing  the 
baths.  Brand  has  continued  them  in  six  cases  with  good  effect,  and  I 
have  seen  no  harm  from  them  in  one  case.  Brand  distinguishes  the 
congestive  hemorrhage  which  occurs  mostly  before  the  fifteenth  day, 
and  which  does  not  forbid  the  bath,  from  that  occurring  later  and  due 
to  diseased  action  in  the  blood-vessels  proper.  If  the  hemorrhage  is 
pronounced  rest  is  imperative,  and  this  alone  requires  abstention  from 
the'  bath,  and  the  temporary  substitution  of  ablutions  given  without 
disturbing  the  patient. 

The  bath  may  be  resumed  as  soon  as  the  hemorrhage  is  stayed. 
Indeed,  this  should  be  a  rule  in  all  cases  in  which  the  bath  has  been 
suspended  for  cause,  for  to  it  we  may  intrust  the  invigoration  of  the 
patient,  which  alone  can  tide  him  over  the  ever-present  dangers  due  to 
the  fever  processes. 


THE   FULL   BATH.  225 

Objection  XIV.  Relapses.  It  has  been  charged  that  relapses  are 
more  frequent  after  the  bath  treatment.  This  is  probably  true,  but 
may  be  explained  by  the  fact  that  'more  cases  survive  to  relapse.  If 
sixteen  more  patients  were  saved  by  the  Brand  method  than  by  the 
expectant  plan,  then  out  of  each  hundred  there  are  sixteen  more  cases 
liable  to  relapse.  Applying  the  usual  percentage  of  relapses  to  these 
sixteen  surviving  cases,  we  have  a  ready  explanation  of  the  apparent 
increase  of  relapses  after  cold  bathing. 

CONTRAINDICATIONS  TO  THE  BATH. — Menstruation  and  pregnancy 
are  regarded  by  the  inexperienced  as  contraindications  to  the  cold  bath 
in  typhoid.  That  this  is  an  error  is  constantly  exemplified  by  the  ob- 
servation of  those  who  bathe  systematically  in  typhoid,  and  this  the 
author  can  positively  confirm.  I  have  frequently  bathed  menstruating 
women,  and  Dr.  F.  H.  Daniels  carried  a  woman  in  the  seventh  month 
of  pregnancy  successfully  through  a  case  of  typhoid  fever  with  the 
Brand  baths  in  the  Manhattan  General  Hospital. 

Pleurisy  indicates  the  cessation  of  the  baths,  because  it  demands 
rest.  If,  however,  the  temperature  be  persistently  high,  with  nervous 
symptoms  threatening,  these  must  be  combated  by  the  bath,  even 
though  pleurisy  be  present.  Brand  has  never  observed  pleurisy  in  his 
335  cases;  Rolet,  in  1,005  cases,  only  four;  Molliere,  only  one  in  234 
cases.  According  to  Betke,  the  mortality  from  this  complication,  which 
is  rare  in  the  cases  treated  by  the  bath,  is  only  0.2  per  cent  in  5,075; 
while  in  1,420  cases  treated  medicinally  it  was  1.4  per  cent.  I  have 
had  one  death  from  it  in  the  Manhattan  General  Hospital.  (Bath  was 
begun  too  late.) 

Severe  cough  and  paroxysms  of  dyspnoea  are  not  rare,  when  pa- 
tients feel  the  first  shock  of  the  bath ;  but  these  symptoms  soon  sub- 
side. Tripier  and  Bouveret  mention  five  cases  in  which  it  persisted 
so  as  to  require  cessation  of  the  baths.  In  some  cases  the  oppression 
of  breathing  is  voluntary ;  the  patient  either  imagines  it,  or  he  simu- 
lates it  in  order  to  alarm  the  attendant  and  prevent  a  continuation  of 
the  bath.  By  reassuring  such  patients  their  apprehension  may  be 
overcome.  If  cyanosis  and  syncope  occur,  the  bath  must  be  discon- 
tinued, but  in  severe  cases  this  should  not  deter  us  from  renewing  it. 
The  graduated  bath,  or  the  wet  pack,  sometimes  helps  these  cases. 
The  cough  produced  by  the  shock  from  the  cold  water  is  advantageous, 
as  it  relieves  the  bronchial  tubes  of  mucus  and  stimulates  pulmonary 
circulation. 

Syncope  and  fainting  have  been  charged  as  causes  of  death  due  to 

cold  bathing.     A  large  experience   readily  disposes  of  this  bugbear. 

Death  from  sudden  heart-failure  is  not  an  unusual  occurrence  in  typhoid 

fever;  the  cold  bath  is,  as  I  have  shown,  the  best  weapon  against  it. 

15 


226        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

Korber  has  shown  that  of  eight  hundred  and  seventy-four  cases  of 
typhoid  treated  by  cold  baths  only  ten  were  fatal  immediately  after 
the  bath,  and  these  were  very  desperate  cases.  "  What  may  be  espe- 
cially dwelt  upon  is  the  fact, "  says  Vogl,  "  that  in  thousands  of  baths 
not  a  single  time  was  collapse  to  be  observed,  either  before,  during,  or 
after  the  bath." 

In  my  own  experience  also  not  a  single  case  of  collapse  has  been 
observed. 

Perforation  and  peritonitis  contraindicate  cold  baths,  because  the 
latter  involve  disturbance  of  rest,  which  is  very  important. 

Xot  only  has  the  claim  that  these  serious  complications  are  some- 
times due  to  the  bathing  been  refuted  by  abundant  and  convincing 
statistics,  with  case  histories,  but  the  fact  has  been  established  that 
they  have  been  reduced  in  frequency.  Murchison's  statistics  of  1,271 
cases  give  196  cases  of  perforation  (11.38  per  cent).  Brand's  4,884 
cases  give  12  perforations  (0.24  per  cent). 

Nephritis. — A  paper  on  "  Urea  Estimation  in  Typhoid  Fever,"  by 
Dr.  James  Tyson,  *  refers  to  a  patient  with  typhoid  fever  who  had  al- 
buminuria  and  hyaline  casts  three  days  after  admission.  He  gave 
milk  and  other  liquid  diet.  The  patient  was  tubbed  five  times  in  one 
day  and  the  secretion  of  urine  and  urea  was  increased  thus : 

Day  of  Disease.  Urine.        Urea. 

28th 2,100  c.c.     29.8percent. 

29th 2,100    "        24.7       " 

30th 2,280     "        32 

The  albumin  fell  to  one-twelfth  per  cent  by  bulk  and  finally  dis- 
appeared, as  did  the  casts.  Cough  grew  less.  There  were  no  tubercle 
bacilli.  An  otitis  media  developed  in  both  ears,  but  there  was  no  defect 
in  the  hearing.  The  nephritis  was  mild. 

Stagnation  of  blood  in  the  kidney  is  dangerous;  therefore  the 
Brand  method  is  not  contraindicated  in  this  passing  nephritis.  Of  sixty- 
nine  soldiers  treated  by  Vogl  five  had  nephritis  and  ail  recovered,  and 
of  sixty-nine  others  not  treated  by  baths  by  the  Brand  method  nine 
had  nephritis  and  five  died.  My  observation  is  entirely  in  accord 
with  that  of  Tyson  and  Vogl. 

Free  perspiration  does  not  contraindicate  the  bath.  The  patient 
should  be  dried  with  friction  before  being  placed  into  it. 

Bedsores  (if  large)  forbid  the  bath,  because  disturbance  of  the  pa- 
tient interferes  with  a  strict  antiseptic  treatment.  General  ablutions 
and  cold  compresses  should  be  substituted. 

*  Medical  Record,  1896. 


THE   FULL   BATH.  227 

Erysipelas  does  not  present  a  reason  for  discontinuing  baths,  so 
long  as  there  is  no  extensive  destruction  of  tissue  accompanying  it. 

Pain. — Severe  aching  of  the  leg  muscles  is  often  complained  of  so 
much  that  the  bath  is  not  repeated  by  timid  practitioners.  This  is  a 
mistake.  Good  friction  will  prevent  this  cramp.  Sometimes  wrap- 
ping the  leg  in  a  thick  flannel  band,  wrung  out  of  hot  water  before  the 
bath,  prevents  cramps. 

Late  cases,  viz.,  cases  coming  under  treatment  after  the  second  or 
third  week,  do  not  forbid  the  bath.  When  the  nervous  system  has 
been  sustained  by  early  bathing,  the  patient  not  only  bears  cold  baths 
with  impunity  in  the  later  stages,  but  improves  constantly  under  their 
invigorating  effect.  If  the  case  comes  under  observation  in  the  middle 
or  last  period  of  typhoid  fever,  the  baths  demand  a  more  cautious  and 
brief  application  and  higher  temperatures.  The  effect  of  such  baths 
will  not  be  so  striking,  and  the  prognosis  cannot  be  expressed  as  being 
so  favorable.  Hospital  histories  demonstrate  that  many  desperate 
cases,  which  under  medicinal  or  expectant  treatment  were  lost,  now  re- 
cover under  judicious  hydriatic  treatment.  The  condition  of  the  heart 
is  the  chief  index  to  the  bath,  or  rather  to  the  kind  of  bath.  To  react 
from  a  bath  of  65°  F.,  a  certain  integrity  of  the  central  nervous  system 
and  of  the  heart-muscles  is  required.  This  is  almost  surely  impaired 
by  a  long-continued  febrile  process  which  has  not  been  moderated  by 
cold  baths,  even  if  no  actual  organic  degenerations  have  been  developed. 
Hence  the  graduated  bath  of  Ziemssen  or  the  wet  pack  is  more  appli- 
cable, or  a  warm  bath  with  cold  affusions  followed  by  friction.  These 
may  restore  the  lost  stamina  and  enable  us  to  resort  to  the  cold  bath, 
if  the  symptoms  demand  it. 

The  author  has  endeavored  to  cover  every  point  in  the  discussion 
of  this  important  subject  and  to  meet  every  objection  and  possible 
difficulty  which  may  occur  to  the  inexperienced. 

After  the  lapse  of  ten  years,  he  has  allowed  this  somewhat  lengthy 
plea  for  the  Brand  bath  to  stand,  because  in  Germany,  where  it  origi- 
nated, it  has  been  emasculated  beyond  recognition  since  its  energetic 
and  able  author,  having  been  removed  from  the  scene  of  his  humane 
activity,  is  not  present  to  defend  his  method  against  baseless  and 
often  misrepresenting  attacks.  When  so  high  an  authority  as  Cursch- 
mau  inveighs  against  the  "  barbarous  method  of  Brand,  who  used 
water  at  50°  F.  (?),"  it  is  not  surprising  that  such  (unwitting)  misrep- 
resentation succeeds  in  alarming  the  profession. 

Delirium  Tremens. — Letulle  *  reports  good  results  from  baths  of  18° 
C.  (64.4°  F.)  of  ten  to  fifteen  minutes'  duration  every  two  or  three  hours, 
according  to  the  seriousness  of  the  case  and  the  temperature.  In  one 

*  Presse  Mcdicale,  No.  59,  1899. 


228       THE    PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

of  his  cases  the  patient  could  scarcely  be  controlled  by  the  "  strait- 
jacket  ";  the  rectal  temperature  was  40.3°  C.  The  bath  was  somewhat 
prolonged — to  twenty-eight  minutes — but  the  patient  became  cyanotic 
and  fell  into  a  collapse  (pulse,  108;  rectal  temperature,  33.9°  C.),  and 
was  rescued  with  great  difficulty.  In  the  other  cases  the  cold  bath 
"gave  excellent  results."  Letulle  regards  it  as  the  best  treatment  in 
delirium  tremens. 

Salvant  *  advises  the  full  bath  in  delirium  tremens  whenever  the 
rectal  temperature  reaches  39°  C.  (102.2°  F.).  If  the  heart  or  arte- 
ries are  defective,  he  applies  the  water  at  25°  C.  to  28°  C.  (77°  F.  to 
82.4°  F.),  or  18°  C.  (64.4°  F.)  when  the  circulation  is  not  seriously 
impaired,  duration  five  to  ten  minutes,  every  three  hours.  The  bath 
should  be  under  direction  of  the  physician,  who  should  never  leave  the 
pulse  unobserved.  Lukewarm  baths  suffice  in  mild  cases  presenting  a 
temperature  below  102°  F.,  or  in  cases  complicated  with  endo-  or 
pericarditis,  myocarditis,  arteriosclerosis,  diabetes,  etc.,  in  which  the 
lukewarm  baths  give  excellent  results. 

*  Centralblatt  f.  d.  gesammte  Therapie,  1903. 


CHAPTER  VII. 
THE  WARM  FULL  BATH. 

A  BATH  prepared  with  water  above  the  temperature  of  the  skin  (92° 
F.)  constitutes  a  warm  bath.  The  term  "  warm  "  being  indefinite,  I 
have  adopted  this  definition  in  order  to  insure  precision.  The  terms 
"  tepid  "  and  "  warm  "  and  "  hot "  will  be  replaced  by  a  statement  of 
definite  temperatures,  in  accordance  with  which  alone  may  definite 
effects,  physiological  or  therapeutic,  be  attained. 

The  warm  bath  demands  a  distinct  chapter,  because  its  technique, 
rationale,  and  therapeutics  differ  widely  from  the  cold  bath  (below 
92°). 

Technique. — The  bathroom  should  have  a  temperature  not  less  than 
70°  F.  and  not  more  than  80°  F.  The  following  articles  should  be 
ready : 

1.  Two  linen  sheets  and  several  soft  towels  thoroughly  heated  in 
laundry  or  on  a  radiator  or  before  a  fire ;    these  should  be  wrapped  in 
flannel  or  a  small  blanket  and  kept  warm  near  the  tub,  until  the  bath 
is  about  to  terminate. 

2.  The  tub  should  be  filled  three-fourths  with  water  at  95°  F. 

3.  A  pair  of  warm  slippers  are  required. 

4.  Several  bags  filled  with  hot  water. 

5.  Provision  for  increasing  the  bath  temperature  rapidly  must  be 
made  before  the  bath.     If  there  is  not  a  hot-  and  cold-water  system 
in  the  house,  large  vessels  containing  water  at  200°  F.  should  be  in 
readiness  for  this  purpose. 

It  may  be  noted  here  that  it  is  much  more  difficult  to  accomplish 
the  latter  than  it  is  to  maintain  the  temperature  of  a  cold  bath,  since 
the  warm  bath  is  usually  twenty  or  more  degrees  above  the  tempera- 
ture of  a  room,  while  the  cold  bath  of  any  decided  duration  is  rarely 
over  five  degrees  below  the  temperature  of  the  room.  It  follows  that 
the  water  of  the  warm  bath  will  cool  off  quite  rapidly  during  the  pro- 
cedure, if  the  above-mentioned  provision  be  not  made. 

When  everything  is  in  readiness  the  patient  bathes  his  face  with 
water  dipped  from  the  tub.  He  now  lies  down  and  the  attendant 
must  insist  on  complete  immersion  during  the  entire  duration  of  the 
bath  ;  though  this  is  a  matter  of  great  importance,  it  is  frequently 
neglected.  Just  before  completion  of  the  bath  the  hot  sheet  is  re- 


230       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

moved  from  its  heat-retaining  envelope.  The  patient  steps  upon  the 
warm  rug  and  is  quickly  enveloped  in  the  hot  sheet ;  the  feet'  are 
slipped  into  warm  slippers  and  he  is  rapidly  taken  to  his  bed,  snugly 
wrapped  in  the  hot  sheet,  without  drying,  and  covered  with  blankets, 
the  hot- water  bags  being  moved  aside  but  not  out  of  the  bed.  In  ten 
minutes  the  sheet  is  used  for  gently  drying  the  patient  and  afterward 
removed.  The  feet  are  separately  dried,  as  also  any  part  of  the  body 
retaining  much  moisture.  If  sleep  be  prevented  by  too  profuse  dia- 
phoresis, the  patient  should  be  dried  without  the  sheet  before  he  re- 
tires after  the  succeeding  baths.  It  is  evident  that  the  entire  aim 
of  this  technique  is  to  retain  the  heat  accumulated  in  the  warm  bath 
as  long  as  possible  after  removal  from  it,  but  abundant  diaphoresis 
must  be  avoided.  Precision  of  the  steps  here  described  is  therefore 
essential.  The  nurse  would  do  well  to  read  the  latter  carefully  be- 
fore proceeding  to  the  bath. 

Warm  Bath  and  Pack. — This  procedure  differs  from  the  ordinary 
warm-bath  technique  chiefly  in  substituting  the  dry  pack  for  the  bed 
after  its  completion.  The  water  temperature  should  be  104°  to  108°  F. ; 
the  duration  five  to  ten  minutes,  both  being  adapted  to  the  patient's 
tolerance.  Massage  around  swollen  joints  or  over  sore  muscles  is 
practised  gently  during  the  bath.  Before  the  patient  is  undressed, 
three  blankets  are  prepared  on  a  cot  or  bed  to  receive  him.  When 
the  bath  is  terminated,  the  hot  sheet  is  thrown  around  him,  he  is 
laid  upon  the  blankets,  and  snugly  enveloped  in  them  successively; 
care  is  demanded  that  there  be  no  loss  of  heat.  The  blankets  are  ap- 
plied as  described  in  the  "  Wet  Pack";  a  cold  compress  is  placed  on 
the  head,  and  the  nurse  administers  two  ounces  of  ice  water  every  ten 
minutes  during  the  pack,  the  duration  of  which  should  not  be  less 
than  one  hour,  unless  the  patient  feels  decidedly  faint  or  the  temporal 
artery  indicates  loss  of  tension.  The  patient  should  never  be  asked  if 
he  is  faint.  After  the  pack  the  body  is  rapidly  dried  and  treated  with 
an  alcohol  rub.  The  patient,  after  resting  half  an  hour,  need  not 
fear  to  go  at  once  into  the  open  air  ;  indeed,  it  is  essential  that  he 
do  so,  if  he  is  well  protected  in  inclement  weather. 

Rationale. — The  warm  bath  exerts  a  positive  effect  upon  the  pe- 
ripheral sensory-nerve  terminals,  which  are  now  regarded  by  physi- 
ologists as  the  outposts  of  the  entire  nervous  system,  conveying 
all  impressions  directly  to  the  brain.  Heyman  and  Krebs  hold  that 
the  nerve  terminals  are  rendered  succulent,  and  thus  become  blunted, 
and  they  substantiate  their  claim  by  demonstrating  that  this  slow 
imbibition  of  water  by  the  nerve  endings  and  their  surrounding 
strmtures  reduces  their  sensibility,  while  a  withdrawal  of  water 
from  them  enhances  the  latter.  In  the  lukewarm  bath  endosmosis 


THE   WARM   FULL   BATH.  231 

fills  these  structures  with  water,  either  by  direct  absorption  or  by 
the  cessation  of  insensible  perspiration.  Kolliker  also  has  shown 
that  succulence  of  the  nerve  terminals  decidedly  diminishes  their  irri- 
tability. A  nerve  which  has  been  lying  in  tepid  water  remains  for. 
a  short  time  somewhat  irritable,  but  loses  its  sensitiveness  to  excita- 
tion more  rapidly  than  a  nerve  exposed  to  the  air  but  protected  against 
desiccation  by  evaporation. 

This  would  furnish  a  reasonable  explanation  of  the  calmative  effect 
of  the  warm  bath,  which  is  now  used  so  successfully  in  nervous  dis- 
eases and  insanity,  in  which  the  water  is  not  raised  above  100°  F. 

When  higher  temperatures  are  applied,  the  increased  thermic  stim- 
ulation overcomes  the  blunted  sensory  terminals  and  produces  the  op- 
posite result. 

The  action  of  temperatures  above  that  of  the  skin  has  been  referred 
to  at  length  in  the  consideration  of  the  influence  of  hydriatric  proce- 
dures upon  the  pulse,  respiration,  tissue  change,  etc.  These  effects  are 
in  proportion  to  the  difference  between  the  temperature  of  the  skin 
(92°  F.)  and  the  temperature  of  the  bath. 

When  the  definitely  ascertained  changes  in  all  the  bodily  functions 
produced  by  these  baths  is  considered  it  becomes  evident  that  there  is 
no  therapeutic  agent  that  can  approximate  its  effects  upon  the  organ- 
ism. An  agent  which  is  capable  of  increasing  the  pulse,  doubling  its 
number  of  beats,  of  elevating  the  internal  temperature  three  degrees, 
of  increasing  oxygen  consumption  78  per  cent  and  COg  elimination  91 
per  cent,  of  changing  the  calibre  of  the  vessels  of  the  internal  organs 
as  well  as  of  the  entire  cutaneous  area,  cannot  fail  to  prove  an  effect- 
ive therapeutic  agent  when  judiciously  applied. 

Oliver  offers  observations  made  with  his  ingenious  arteriometer 
and  other  instruments  of  precision,  to  ascertain  the  influence  of  baths 
upon  the  vasomotor  system.  Hot  immersion  baths  (100°  to  105°  F.) 
quickly  reduced  the  radial  calibre  and  blood  pressure  by  reason  of  the 
rapid  dilatation  which  takes  place  in  the  arterioles  of  the  cutaneous 
surface.  To  this  dilatation  may  be  ascribed  the  increase  in  volume 
in  limbs  observed  immediately  after  the  immersion  of  the  body.  This 
enlargement  rapidly  subsides.  In  one  example  the  initial  volume  of 
1,640  c.c.  was  raised  by  the  hot  bath  to  1,744  c.c.,  which  fell  in  five 
minutes  to  1,680  c.c.,  and  in  ten  minutes  to  1,664  c.c.  The  enlarge- 
ment was  obviously  due  to  a  temporary  turgescence  of  the  vessels  of 
the  skin.  Warm  immersion  baths  (96°  to  100°  F.),  for  instance,  en- 
larged the  radial  calibre,  though  after  a  certain  time  the  peripheral 
vessels  became  relaxed  and  full,  the  radial  artery  being  consequently 
reduced  in  calibre. 
In  a  full  bath  of  90°  to  100°  F.,  given  to  one  of  the  attendants  at 


232        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

the  Hydriatric  Institute,  I  found  the  pulse  not  materially  affected. 
It  became  somewhat  more  rapid  at  the  time  that  the  bath  was  entered, 
increasing  slowly  in  fulness  and  firmness  as  the  body  became  fully 
submerged.  After  15  minutes'  immersion  at  a  temperature  of  100°  F., 
the  pulse  became  more  frequent,  soft,  and  compressible.  These  changes 
were  rapidly  compensated  after  the  bath  was  left. 

The  calming  effect  of  a  warm  bath  on  the  respiration  is  decidedly 
pronounced.  In  my  own  experiments  the  respiration  was  reduced  by 
ten  per  cent  in  a  bath  at  100°  F. 

It  must,  however,  be  borne  in  mind  that  the  effect  of  a  warm  bath 
is  in  accordance  with  the  previous  temperature  in  which  the  individual 
has  been  placed.  When,  for  instance,  a  bath  of  90°  F.  is  entered  after 
undressing  in  a  temperature  of  60°  F.,  such  a  bath  would  feel  much 
warmer  than  it  would  after  undressing  in  a  temperature  of  80°  F.  or 
over.  And  yet  such  a  bath  is  not  a  warm  bath,  but  one  of  neutral 
temperature.  A  bath  of  90°  F.  would,  if  continued  twenty-five  or 
thirty  minutes  without  friction,  gradually  chill  the  patient,  because 
the  water  would  become  cooler  and  the  individual  would  have  lost 
much  of  his  reactive  capacity.  When  issuing  from  such  a  bath  it  is 
•important  that  the  patient  should  be  thoroughly  dried,  placed  between 
warm  cotton  sheets,  and  supplied  with  artificial  warmth  to  aid  reaction. 

When  the  temperature  of  the  bath  is  raised  above  104°  F.  the  effect 
is  quite  different,  because  its  modus  operandi  is  different.  The  heart 
is  called  upon  to  labor  more  actively.  There  is  no  longer  a  primary 
relaxing  effect  upon  the  peripheral  vessels,  but  an  intense  stimulating 
effect  upon  the  vasoconstrictors,  which  very  soon  fatigues  the  latter 
and  eventuates  in  a  dilatation  of  the  vessels,  filling  the  skin  with 
blood,  which,  being  heated,  raises  the  internal  temperature  decidedly. 
The  pulse  rises  in  frequency,  becoming  feeble  if  the  temperature  be 
raised  to  110°  and  the  bath  be  prolonged;  collapse  threatens;  but  re- 
moval from  the  bath  is  followed  by  a  feeling  of  comfort  and  lightness. 

Baelz,  of  Tokio,  has  furnished  accurate  observations  on  the  hot 
bath.  Residing  among  a  people  with  whom  hot  bathing  is  a  daily 
practice,  there  being  four  hundred  thousand  hot  baths  given  daily  in 
Tokio  alone,  he  had  exceptional  opportunities  for  studying  their 
effects.  The  temperature  adopted  by  the  Japanese  is  usually  about 
130°  F. ;  Europeans  indulge  in  baths  of  104°  to  109°.  The  head  is 
usually  bathed  in  hot  water  before  the  bath  is  entered,  in  order  to  relax 
and  dilate  the  cerebral  vessels,  and  thus  prevent  cerebral  anaemia  when 
the  cutaneous  vessels  become  greatly  dilated.  This  is  also  aided  by 
the  sitting  posture  usually  assumed.  Palpitation  of  the  heart  and  a 
decided  sense  of  great  heat  are  regarded  as  a  signal  for  removal.  The 
'  first  effect  of  such  a  bath  is  a  cutis  auserina  and  pallor  of  the  skin, 


THE    WARM   FULL   BATH.  233 

lasting  a  few  seconds;  the  pulse  becomes  slower  and  afterward  more 
rapid.  At  first  the  respiration  is  not  much  affected ;  later  it  becomes 
purely  thoracic.  The  temperature  of  the  body  rises  slowly  to  104°  and 
over,  this  effect  being  due  to  heat  retention  combined  with  direct  ab- 
sorption of  heat.  It  occurs  rapidly,  often  within  six  minutes;  but  it 
returns  to  normal  in  half  an  hour  after  the  bath.  The  arteries  become 
relaxed,  the  temporal  artery  assumes  a  dendritic  form  as  in  arterio- 
sclerosis. The  pulse  is  full;  its  curve  is  high.  Prolonged  stay  in  the 
bath  produces  vertigo  and  nausea.  The  consumption  of  albuminoids 
is  not  increased  by  the  hot  bath.  On  leaving  the  bath,  abundant  per- 
spiration ensues.  The  Japanese  apply  cold  affusion  before  leaving  the 
bath.  It  is  a  common,  error  to  suppose  that  colds  are  easily  taken  after 
hot  baths.  According  to  Baelz,  this  is  impossible.  While  a  warm  bath 
relaxes  the  vasoconstrictors  and  thus  predisposes  to  cold,  the  very 
hot  bath  produces  a  paralysis  of  the  cutaneous  vessels,  which  lasts  some 
time  and  prevents  their  contraction  when  exposed  to  cold.  This  is 
proved  by  the  fact  that  the  Japanese  often  run  naked  on  the  streets 
after  their  hot  baths  without  taking  cold.  Nor  does  such  a  bath  pro- 
duce tenderness  and  consequently  debility.  On  the  contrary,  it  seems 
to  stimulate  and  tone  them  up;  but  there  is  usually  a  slight  loss  of 
weight  after  continuous  use.  The  sense  of  warmth  produced  by  the 
Japanese  hot  baths  is  claimed  to  be  so  enduring  that  it  is  regarded  as 
an  economical  method  of  keeping  the  body  warm  in  winter  in  dwellings 
which  are  not  heated. 

The  distribution  of  blood  in  the  body  is  decidedly  affected  by  hot 
baths,  according  to  the  experiments  referred  to.  The  hotter  the  bath, 
the  greater  is  the  turgescence  of  the  cutaneous  vessels  and,  pari  passu, 
the  more  contracted  must  the  interior  vessels  become.  That  an 
anaemic  condition  of  the  brain  ensues,  as  demonstrated  by  Schuller, 
is  proved  by  the  sense  of  pressure  on  the  head  experienced  in  a  hot 
bath  and  the  frequent  occurrence  of  vertigo  when  rising  from  such  a 
bath. 

There  is  a  decided  difference  of  susceptibility  to  heat  in  different 
parts  of  the  body;  the  feet  are  more  sensitive  than  the  hands,  and  the 
male  sexual  organs  are  more  sensitive  than  is  any  other  part  of  the 
body. 

The  effects  of  warm  (near  the  temperatiire  of  the  skin)  and  hot 
(above  the  body  temperature)  baths  differ  also,  as  may  be  supposed, 
according  to  the  extent  to  which  the  body  is  submerged. 

Topp*  confirms  the  view  of  Baelz  that  the  feeling  of  bien  aise  after 
hot  (110°  F.)  baths  taken  after  great  muscular  exertion  is  due  to 
removal  of  fatigue  products  by  the  increase  of  oxidation. 

*  Therapeutische  Monatshefte,  February,  1894. 


234       THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

Therapeutic  Indications. — The  warm  bath  offers  a  potent  means  for 
reducing  the  temperature,  assuaging  pain,  and  relieving  nervous  de- 
bility, without  materially  interfering  with  any  of  the  functions,  in 
all  the  pyrexias  of  infants  and  very  young  children.  There  is  no 
remedial  agent  which  can  compare  with  a  full  bath  of  98°,  reduced 
perhaps  to  90°  for  eight  to  ten  minutes,  with  gentle  friction,  for  these 
purposes.  The  pronounced  involvement  of  the  nervous  system  in  the 
febrile  conditions  of  infants  and  very  young  children  demands  a  meas- 
ure which  calms  these  threatening  symptoms  without  interfering  with 
the  secretions.  Care  should  be  taken  in  drying  the  patient  carefully 
and  furnishing  quiet  surroundings  to  encourage  sleep  after  such  a  bath ; 
also  in  watching  that  the  child  does  not  expose  its  body  by  uncovering 
or  restlessness  and  thus  incur  the  action  of  the  contrasting  tempera- 
ture of  the  air.  In  this  day  of  facile  resort  to  antipyrin  and  its  con- 
geners, the  following  large  statistical  evidence  may  be  of  value.  In 
the  Jahrbuch  fur  Kinder heilkunde  (xxxii.,  142)  Eroess  reports  the 
results  of  his  observations  upon  the  use  of  antipyrin,  quinine,  and 
warm  baths  in  the  pyrexia  of  very  young  infants :  "  Among  four  hun- 
dred and  thirty -one  cases  of  fever  during  the  first  ten  days  after  birth, 
one  hundred  and  forty-five  were  of  short  duration,  the  remainder  con- 
tinuing for  several  days;  in  one  hundred  and  eighty -four  it  was  con- 
tinuous, and  in  most  of  the  others  irregular.  In  forty-four  per  cent  it 
was  attributable  to  gastro-intestinal  disorder,  in  thirty -four  per  cent  to 
some  disorder  connected  with  the  navel.  Antipyrin  was  given  in  doses 
of  from  one  grain  to  two  and  one-fourth  grains,  repeated,  if  necessary, 
in  an  hour.  The  effect  was  good,  as  was  that  of  quinine.  Better  re- 
sults were  obtained  from  the  warm  baths  than  from  either  drug.  The 
temperature  of  the  bath  was  95° ;  duration,  ten  minutes ;  in  weakly 
children,  five  minutes.  Upon  the  general  condition  the  result  was 
very  satisfactory.  Sleeplessness  and  irritability  usually  disappeared, 
and  the  child  fell  into  a  quiet  sleep,  from  which  he  awoke  apparently 
improved.  When  the  temperature  is  very  high,  a  warm  bath  is  an 
agent  of  the  greatest  value. " 

There  are  few  febrile  diseases  of  children  in  which  I  do  not  pre- 
scribe such  baths,  and  usually  with  the  most  satisfactory  results.  So 
popular  have  they  become  that  mothers  have  termed  them  "  reducing 
baths  "  and  applied  them  frequently  before  calling  me  in. 

In  insomnia,  a  manifestation  occurring  in  neurasthenia  and  other 
neuroses,  the  warm  bath  before  retiring  is  often  prescribed  in  a  rou- 
tine fashion,  but  it  is  rarely  efficient  because  the  technique  is  faulty 
and  in  contravention  to  well-ascertained  physiological  principles.  The 
prescription  "  Take  a  warm  bath  at  bedtime  "  fails  because  the  tem- 
perature, duration,  and  other  important  details  are  omitted.  When 


THE   WARM    FULL   BATH.  235 

a  patient  rises  from  a  bath  of  100°  F.  or  over,  the  cutaneous  vessels 
are  relaxed  and  dilated.  The  air  of  the  bathroom  being  usually  about  70° 
F.,  the  skin  is  at  once  subjected  to  an  environment  25°  below  its  recent 
temperature.  During  the  passage  from  the  bathroom  to  the  bed  the 
skin  is  gradually  cooled,  and,  having  been  rendered  more  sensitive  by 
the  heat,  there  is  a  decided  lowering  in  it,  not  rarely  accompanied  by 
cutis  anserina.  The  rationale  of  the  warm  bath  as  established  by 
Max  Schtiller's  trephined-rabbit  experiment  is  thus  contravened. 

In  chronic  rheumatism  and  gout  the  hot-pack  bath  described  above  is 
of  the  greatest  value,  often  rewarding  with  success  after  other  reputed 
measures  have  failed.  Faithful  execution  of  the  technique,  especially 
the  cautious  massage,  during  the  bath,  of  parts  in  the  immediate  vicin- 
ity of  the  diseased  parts,  is  essential.  These  procedures  may  be  re- 
sorted to  daily  or  alternated  in  feeble  subjects  with  tonic  procedures. 

In  cardiac  affections  the  warm  bath  is  usually  regarded  as  contra- 
indicated,  but  the  injurious  effects  are  often  due  to  improper  execution 
of  the  bath.  It  should  not  be  of  so  high  a  temperature  as  to  heat  the 
blood ;  nor  should  the  patient  dress  in  the  room  in  which  he  has  bathed 
and  which  contains  much  moisture ;  nor  should  he  make  great  efforts 
in  drying  or  dressing  himself. 

Hoffman  says  justly  that  all  these  faults  may  be  avoided,  if  the 
pulse  and  temperature  are  watched.  With  due  regard  to  these  pre- 
cautions, the  warm  bath  is  an  excellent  remedy  to  regulate  cardiac 
action,  and  as  a  method  of  saving  labor  for  the  heart  it  has  a  great  fu- 
ture, because  it  may  be  continued  indefinitely.  An  unavoidable  danger 
from  the  warm  bath  lies  in  its  action  upon  the  skin.  The  perspiration 
is  greatly  increased,  the  epidermis  becomes  succulent  and  better  adapted 
for  giving  off  watery  vapors ;  hence  there  is  a  tendency  to  cooling  off 
after  the  bath,  which  may  amount  to  a  sense  of  chilliness.  A  rapid 
contraction  of  the  cutaneous  vessels  takes  place.  Thus,  while  it  is  our 
desire  to  relieve  the  heart,  these  decided  variations  in  blood  pressure 
make  an  increased  demand  upon  it.  If  to  avoid  this  we  carefully 
cover  the  patient,  we  incur  the  danger  of  fixing  upon  the  cutaneous 
surface  a  layer  of  air  which  is  saturated  with  vapor,  which  maintains 
the  dilatation  of  the  cutaneous  vessels  and  justly  inspires  the  patient 
with  the  fear  of  taking  cold.  The  tone  of  the  vasomotors  is  dimin- 
ished in  these  persons.  Under  normal  conditions  the  vasomotor  sys- 
tem provides  for  the  proper  distribution  of  blood  in  the  whole  bodj^, 
by  preventing  excessive  contraction  as  well  as  dilatation.  This  equi- 
librium is  disturbed  by  the  warm  bath,  and  a  certain  period  is  neces- 
sary for  restitution  of  the  normal  tone  of  the  surface  vessels.  In  the 
healthy  heart  a  cold  affusion  readily  promotes  the  latter.  But  this 
cannot  be  regarded  as  a  quieting  procedure  in  abnormal  cardiac  con- 


236        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

ditions  and  is  advisable  only  for  persons  having  vigorous  hearts. 
Hence  it  becomes  important  that  the  patient's  cutaneous  vascular 
tone  be  restored  gradually.  This  may  be  done  by  rendering  the  skin 
slowly  more  bloodless  by  means  of  gradually  drying  with  warm  cloths. 
This  may  seem  a  trivial  matter,  but  just  such  trifles  render  treatment 
effectual  or  harmful.  Moreover,  too  active  friction  should  be  avoided 
in  these  cases,  and  woollen  clothing  should  be  worn.  The  latter  not 
only  protects  the  skin,  which  has  been  rendered  tender  and  sensitive 
by  the  warm  bath,  but  encourages  by  its  roughness  a  certain  amount  of 
hypersemia,  which  conduces  to  an  increase  of  vascular  tone.  In  ad- 
vanced conditions  of  cardiac  disease  still  greater  care  is  necessary  in 
the  use  of  warm  baths.  So  long  as  there  is  no  venous  stasis,  they 
may  be  used  with  advantage. 

In  cerebro- spinal  meningitis  such  good  results  have  been  observed 
in  isolated  cases  that  the  application  of  these  baths  should  not  be 
omitted.  Aufrecht*  reports  the  case,  occurring  during  a  fatal  epidem- 
ic, of  a  laborer,  twenty-five  years  old,  who  had  lain  in  a  somnolent 
condition  for  ten  days.  A  spontaneous  cure  was  out  of  the  question. 
The  low  temperature  and  small  frequent  pulse  impelled  Dr.  Aufrecht 
to  resort  to  hot  baths.  The  patient  received  altogether  twelve  baths 
of  ten  and  twenty  minutes'  duration.  After  the  first  few  baths  an 
improvement  was  noted.  The  sensorium  gradually  cleared  up ;  stiff- 
ness of  the  neck  and  pain  were  diminished;  he  began  to  call  for  ves- 
sels when  prompted  to  urinate  or  defecate;  the  abducens  muscles 
resumed  their  normal  function  and  condition.  When  the  baths  were 
discontinued  after  nine  had  been  administered,  headache,  great  rest- 
lessness, and  delirium  returned.  These  symptoms  disappeared,  how- 
ever, after  three  more  baths  were  given. 

Eogansky  confirms  Aufrecht's  statements,!  having  during  a  period 
of  five  years  treated  fifty-one  women  with  hot  baths  (104°  F.)  for  fif- 
teen or  twenty  minutes  twice  a  day,  with  ice-bag  to  the  head.  The 
effects  were  most  striking  in  subdelirious  patients,  who  often  recovered 
consciousness  rapidly,  after  the  third  bath,  and  became  more  calm  if 
not  restored  to  consciousness.  The  temperature,  vomiting,  and  cervi- 
cal rigidity  were  not  so  markedly  influenced.  Of  51  cases,  34  were 
cured,  17  died,  a  mortality  of  33  per  cent.  In  the  male  wards,  where 
this  bath  treatment  was  not  applied,  40  died  out  of  50  cases. 

Voroschitsky  \  reports  two  cases  of  cerebro-spinal  meningitis  which 
were  cured  by  hot  baths.  One  was  that  of  a  man  twenty-five  years  old, 
of  tuberculous  habit,  but  he  was  well  until  September,  1894.  He  pre- 

*  Therapeutische  Monatshefte,  1894,  No.  8. 

f  Modern  Medicine,  October,  1904. 

j  Gazette  Hebdomadaire  Russe,  1895,  No.  4. 


THE   WARM   FULL  BATH.  237 

sented  the  characteristic  signs  of  meningitis,  intense  headache,  vomiting, 
stiffness  of  the  neck,  general  hypersesthesia;  pulse,  60;  temperature, 
37.8°  C.;  no  ocular  symptoms.  These  manifestations  became  aggra- 
vated; the  pulse  became  irregular  and  slower,  and  great  adynamia  en- 
sued. In  this  condition  the  first  warm  bath  was  given,  which  produced 
slight  amelioration  of  the  general  condition,  but  which  on  repetition 
decidedly  improved  all  the  symptoms.  After  the  eighth  bath  recovery 
was  almost  complete.  The  baths  were  given  daily  for  ten  minutes; 
temperature,  32°  K.  (104°  E.). 

A  second  case,  more  serious  on  account  of  cardiac  feebleness, 
also  ended  in  recovery.  The  author  attributes  great  importance 
to  the  warm  baths,  because  he  had  employed  the  customary  medica- 
tion in  both  cases  without  the  slightest  effect  upon  the  progress  of 
the  case. 

Wollisch*  reports  seven  severe  cases  of  cerebro-spinal  meningitis. 
Being  encouraged  by  the  report  of  Aufrecht  and  another  of  Voro- 
schitsky,  he  applied  hot  baths  in  one  case  and  was  induced  by  the  favor- 
able result  to  apply  them  in  six  others.  In  all  seven  cases  (children  from 
five  to  ten  years)  the  symptoms  were  pronounced.  Stiffness  of  the 
neck  was  prominent;  the  disease  was  epidemic.  Five  cases  ended  in 
recovery,  two  ended  fatally.  One  of  the  latter  was  foudroyant  and 
terminated  within  forty-eight  hours;  the  other  patient  died  in  a 
later  stage,  the  baths  having  been  administered  during  the  first  two 
weeks  and  all  other  therapeutic  measures  having  been  impossible  of 
execution. 

The  entire  course  of  the  disease  was  rendered  mild  by  these  baths. 
The  favorable  influence  on  the  heart  and  nervous  system  was  well 
marked.  The  baths  were  administered  in  a  somewhat  different  manner 
from  Aufrecht' s  method.  The  patient  was  put  into  a  bath  of  the  tem- 
perature of  90°,  and  gradually  hot  water  was  added  until  the  tempera- 
ture of  the  water  reached  102°.  During  the  bath  the  ice  bag  or 
Leiter's  coil  was  applied  to  the  head. 

The  transportation  from  the  bed  to  the  bath  should  be  conducted 
most  carefully  and  as  quickly  as  possible.  If  a  great  deal  of  pain  is 
present  in  the  spine,  the  patient  must  be  lifted  out  of  the  bed  by 
means  of  the  sheet  on  which  he  lies,  and  with  it  lowered  into  the 
bath.  The  head  should  not  be  touched  during  transportation.  After 
the  bath  the  patient  is  wrapped  in  a  woollen  blanket  and  has  a 
light  cover  thrown  over  him ;  no  drying  or  rubbing  of  the  body  is  to 
be  attempted.  In  this  envelopment  the  patient  is  to  remain  an  hour, 
when  he  may  be  removed.  The  time  of  day  for  the  bath  is  unimpor- 
tant, but  the  very  early  morning  hours  or  late  evening  hours  should  not 
be  selected. 

*  Therapeutische  Monatshefte,  March,  1896. 


238       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

Besides  the  bath  it  is  necessary  to  be  provided  with  good,  cooling 
apparatus  for  the  head,  neck,  and  spine.  The  diet  should  consist  of 
nourishing  meat  preparations,  even  when  diarrhoea  conies  on.  The 
author  also  ordered  his  patients  wine  and  cognac  (in  milk) ;  also  beer, 
as  much  as  they  would  take,  and  came  to  the  conclusion  that  alcohol 
maintains  its  place  also  in  this  disease  as  a  tonic  and  hypnotic  of  the 
first  rank. 

The  question  as  to  the  manner  in  which  hot  baths  act  he  was  not 
in  a  position  to  answer,  but  he  thought  it  not  improbable  that  the 
hyperaemia  of  the  skin  produced  by  the  bath  was  followed  by  a  dimi- 
nution of  blood  in  the  brain  and  spinal  cord,  and  hence  the  bath  acted 
like  venesection  without  the  loss  of  blood  from  the  body.  Further- 
more it  is  reasonable  to  suppose  that  the  sweating  which  usually  fol- 
lows diminishes  the  formation  and  hastens  the  excretion  of  toxins.  At 
least  it  is  certain  that  the  hot  bath,  even  in  the  presence  of  fever,  does 
not  raise  the  temperature  of  the  body,  but  on  the  contrary  diminishes 
it.  In  not  a  single  case  did  he  observe  any  dangerous  influence  of  the 
bath  on  the  heart's  action.  Even  in  a  case  in  which  he  had  ready  for 
instant  use  cognac  and  camphor,  expecting  a  depressing  influence  from 
the  hot  bath,  no  bad  symptom  occurred.  On  the  contrary,  his  observa- 
tions have  satisfied  him  that  the  action  on  the  heart  is  rather  that  of  a 
tonic  and  a  regulator  of  the  heart  beats.  Lastly,  he  would  recommend 
the  use  of  the  hot  baths  in  cases  of  cerebro- spinal  meningitis  even 
when  no  other  benefit  was  to  be  gained  than  the  relief  of  pain  and  the 
calming  results  which  follow. 

In  menstrual  disorders  the  warm  bath  is  an  old  domestic  remedy. 
The  temperature  and  duration  not  being  stated,  it  follows  that  those 
who  attempt  to  obtain  the  results  lauded  by  others  usually  fail. 
Soranus,  of  Ephesus,*  who  paid  special  attention  to  gynaecology,  rec- 
ommends and  describes  the  preparation  of  baths  and  half -baths  for 
dysmenorrhoea  and  amenorrhcea,  followed  by  rest  in  bed.  A  more 
modern  author,  Graily  Hewitt,  f  says :  "  The  warm  bath  in  which  the 
patient  remains  half  an  hour  is  perhaps  one  of  the  most  effective  rem- 
edies for  the  relief  of  the  great  pain,  and  in  many  cases  its  effect  in 
producing  the  flow  is  not  less  marked,  so  that  it  possesses  not  only 
palliative  but  also  curative  properties." 

With  regard  to  temperature  I  have  used  in  amenorrhoaa,  with- 
out recognizable  constitutional  or  organic  defect,  the  half-bath  in 
water  of  95°  gradually  raised  to  100°,  for  half  an  hour,  the  water 
reaching  to  above  the  navel,  especially  if  preparations  are  made 
in  advance  to  secure  rapid  drying  and  getting  into  a  warm  bed. 

*  Quoted  by  Herzl,  in  Winternitz,  "Festschrift." 
t  "  Pathology  and  Treatment  of  Diseases  of  Women." 


THE  WARM   FULL  BATH. 


239 


Such  baths,  alternating  if  anaemia  be  present  with  hip  baths  of  three 
minutes'  duration,  followed  while  the  patient  is  in  the  tub  with  affu- 
sion over  the  shoulders  with  water  at  75°,  are  exceedingly  valu- 
able. The  warm  and  cold  baths  are  to  be  alternated  on  succeeding 
nights. 

For  dysmenorrhcea  the  hot  half-bath,  100°  raised  to  115°  for  twenty 
minutes,  often  acts  like  a  charm. 

Topp  recommends  hot  baths  in  bronchitis.  Drs.  A.  Jacob!  and 
Leonard  Weber,  of  this  city,  laud  them  in  the  bronchitis  of  children, 
and  in  the  same  disease  Baelz  attributes  a  specific  effect  to  baths  of  104° 
to  110°  F.,  three  or  four  times  a  day.  In  nephritis,  rheumatism,  va- 
rious exudations,  uterine  colic,  they  are  very  useful.  These  hot  baths 
are  contraindicated  when  the  heart  is  weak  and  whenever  internal  con- 
gestions are  threatening.  Atheromatous  patients  and  cases  of  angina 
pectoris  require  special  warning. 

In  ivy  poisoning  Dr.  "Barney,  of  the  United  States  Army,  has  found, 
after  exhausting  all  the  usual  remedies,  the  soaking  or  sponging  with 
water  at  110°  to  120°,  or,  better,  submerging  the  affected  parts  in  the 
hot  water,  superior  to  all  the  usual  vaunted  remedies.* 

THE  PROLONGED  WARM  BATH. 

This  valuable  therapeutic  agent  is  prepared  as  follows :  A  large 
bath-tub  is  placed  in  a  pleasant  room  convenient  to  the  water  supply. 
By  an  arrangement  of  buttons  or  a  bar  along  the  outside  of  the  edge  of 

the  tub,  the  edges  of  a  sheet 
may  be  secured  by  means  of 
tapes.  The  sheet  is  in  this 
manner  suspended  within  the 
tub  so  that  its  lower  portion 
clears  the  bottom  of  the  lat- 
ter when  the  patient  is  lying 
upon  it  as  in  a  hammock.  A 
very  deep  tub  being  required 
in  order  to  make  the  patient 
comfortable,  and  such  tubs 
not  being  readily  obtainable, 
the  author  would  call  atten- 
tion to  a  device  which  he  has  applied  successfully  for  the  purpose  of 
improvising  a  prolonged  bath.  A  hammock  may  be  constructed  of  a 
strong  piece  of  sheeting,  the  edges  of  which  are  securely  fastened  by 


FIG.  46.—  Hebra's  Continuous  Bath. 


*  Jour.  Amer.  Med.  Assn.,  August  23d,  1905. 


240       THE    PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

tacks  to  a  frame  of  boards,  four  inches  wide,  seven  feet  long,  and  three- 
fourths  inch  thick.  This  frame  may  be  placed  upon  any  large  and 
deep  tub  in  such  manner  that  the  large  sheet  barely  clears  the  bottom. 
An  arrangement  for  maintaining  temperature  about  95°  to  100°  is  de- 
manded. 

Dr.  Guy  L.  Hunner,  of  Johns  Hopkins  Hospital,  has  devised 
ingeuius  "brass  bath-tub  clamps"  to  fasten  the  sheet  to  the  upper 
borders  of  the  tub. 

The  author  has  found  ordinary  hard- wood  clothes  pins  useful  for 
this  purpose,  provided  they  are  moistened  to  prevent  slipping  off. 

Another  extemporized  hammock  bath  is  described  in  the  manage- 
ment of  extensive  burns  (p.  244). 

A  complete  and  reliable  apparatus  for  permanent  baths  may  be 
constructed  as  follows.*  The  litter  upon  which  the  patient  is  low- 


FIG.  47.— Hammock  Bath.      Method  of  securing  sheet.      Patient's  trunk  must  be  submerged 

entirely. 


ered  into  the  bath  is  constructed  of  a  frame  of  ash,  upon  which  water- 
proof sailcloth  is  stretched.  These  form  a  comfortable  bed,  which 
may  be  shortened  or  lengthened  by  springs;  the  headpiece  is  also 
movable  at  different  angles.  The  litter  is  connected  with  a  metallic 

*Kast's  "  Jahrbiicher  der  Hamburger  Staatskrankenanstalten, "  i. ,   1889. 
F.  W.  C.  Vogel,  Leipzig. 


THE   WARM   FULL   BATH.  241 

frame  to  which  the  lifting  apparatus  is  secured.  When  the  litters  are 
lowered,  a  polished  board  cover  protects  the  patient,  maintains  heat, 
and  serves  also  as  a  table  during  meals.  The  temperature  regulation 
may  be  obtained  by  various  electrical  and  other  contrivances.  It 
should  not  vary  much  from  100°  F.,  for  surgical  or  dermatological  pur- 
poses. The  patient  is  lifted  daily  out  of  the  water,  is  thoroughly 
cleansed  Avith  soap  and  brush;  the  water  is  renewed.  Urine  is  re- 
moved by  outflow,  also  fluid  faeces.  When  solid,  the  latter  may  be 
scooped  up  or  hurried  through  the  outflow,  as  it  floats. 

The  first  sensation  experienced  by  the  patient  after  entering  such 
a  bath  is  one  of  slight  chilliness,  which  subsides  very  soon  and 
gives  way  to  a  sense  of  comfort,  provided  the  temperature  of  the 
water  is  not  permitted  to  sink  below  95°.  The  latter  is  assured 
with  a  good  supply  of  hot  water  and  proper  arrangements  for 
adding  it  to  the  bath  and  for  removing  the  cold  water.  The  tub  should 
be  covered  with  blankets,  placed  on  supports  laid  across  it,  to 
exclude  the  air  as  much  as  possible  and  to  protect  the  patient  against 
exposure.  Such  a  bath  is  usually  continued  for  a  large  part  of  the 
day  and  night,  the  patient  being  carefully  removed  for  the  purpose  of 
urinating  and  defecating.  If  he  cannot  sleep  in  the  bath  he  may  be 
placed  in  an  adjoining  bed  for  that  purpose,  he  having  of  course  been 
previously  dried.  If  the  necessities  of  the  case  demand  his  sleeping  in 
the  bath,  careful  watch  should  be  kept  to  prevent  his  head  slipping 
down  into  the  water.  The  constant  attendance  of  a  nurse  is  usually 
required. 

Before  he  is  placed  in  the  bath  the  patient's  skin  should  be 
anointed  with  mutton  suet,  to  prevent  puckering  and  peeling,  which 
sometimes  ensue  from  prolonged  saturation. 

Prolonged  baths  of  shorter  duration  are  so  useful  in  some  diseases 
that  their  technique  requires  special  description  (see  Nephritis). 

To  Riess,  who  has  studied  this  unique  bath  method  thoroughly  in 
a  large  number  of  cases  in  the  Berliner  stadtisches  allgemeines  Kran- 
kenhaus,  from  1874  to  1876,  we  owe  all  that  is  known  of  its  applica- 
tion for  the  treatment  of  internal  diseases. 

Rationale. — The  physiological  effects  upon  the  organism  which  may 
be  expected  from  lying  in  a  bath  of  from  94°  F.  to  95°  F.,  either  contin- 
uously night  or  da}-,  or  for  a  number  of  hours,  are  of  a  negative  charac- 
ter. There  is  neither  a  thermic  irritation  of  the  sensory  cutaneous 
nerve  endings,  nor  any  change  in  the  cutaneous  vessels,  blood  pressure, 
cardiac  action,  or  respiration.  In  every  case  in  which  Riess  applied 
the  continuous  bath  he  made  careful  temperature,  pulse,  and  respira- 
tion measurements,  which  demonstrated  that  the  last  two  usually 
fluctuated  only  for  a  short  time  after  the  bath  was  entered.  The 
16 


242        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHEKAPY. 

most  reasonable  explanation  of  the  effect  of  the  continuous  warm  bath 
is  to  be  sought  in  the  diminution  or  removal  of  those  cutaneous  irrita- 
tions (rapidly  changing  temperatures,  etc.)  which  are  in  operation  in 
the  ordinary  contact  of  the  body  with  air,  and  the  resultant  effect  of 
this  freedom  from  communicated  irritating  influences  upon  the  inner 
organs,  especially  the  nervous  system.  The  regulation  and  quiescence 
of  important  functions,  especially  of  the  activity  of  the  central  nervous 
system,  ensues  as  a  natural  result. 

Hebra*  was  the  first  to  call  attention  in  1877  to  the  fact  that  pro- 
longed residence  in  this  water-bed  does  not  affect  the  patient  unfavor- 
ably; patients  become  so  readily  accustomed  to  it  that  they  sleep  well ; 
appetite,  bowels,  and  urine  and  respiration  are  normal,  and  there  is  no 
sign  of  any  debilitating  effect.  This  statement  is  confirmed  by  the 
report  of  1897  of  the  Hamburg  hospitals,  which  is  the  most  extensive 
statistical  evidence  of  the  value  of  the  permanent  bath.  The  author, 
Dr.  Zuschlag,  confirms,  on  page  117,  Hebra' s  statement.  He  warns, 
however,  that  during  the  first  two  or  three  days  sleep  is  not  satisfac- 
tory in  sensitive  individuals;  the  appetite  increases  often  to  a  surpris- 
ing hunger,  and  weight  increases.  The  patient  does  not  require  removal 
after  defecation  or  urination,  nor  during  menstruation.  Zuschlag 
mentions  one  case  which  remained  day  and  night  for  fifteen  months. 
The  hard  skin  on  the  soles  and*on  the  palms  became  painful  for  a  few 
days,  while  it  softens.  The  patient  is  rubbed  with  lanolin  before 
entering  the  bath. 

Therapeutic  Indications. — Pemphigus  was  probably  the  first  disease 
subjected  to  the  continuous  bath.  To  Hebra  belongs  the  credit. 
Kaposi  f  writes :  "  The  continuous  bath  is  an  inestimable  measure  in 
pemphigus  foliaceous,  and  assists  best  to  relieve  the  pains,  mitigate  the 
fever,  and  by  restoring  sleep  and  appetite  to  tide  the  patient  over  the 
period  of  eruption  to  which  he  would  succumb  early.  We  have 
treated  in  this  manner  one  case  for  four  years;  sometimes  lying  in  the 
water  night  and  day  for  eight  months  with  the  greatest  benefit." 

Eiess  J  has  rendered  a  great  service  by  an  extensive  report  on  this 
valuable  remedial  agent  in  many  intractable  and  painful  diseases. 

The  clinical  results  obtained  by  his  extensive  observations  are 
in  accord  with  the  rationale.  The  continuous  bath  is  useful  in  serious 
disturbances  of  the  central  nervous  system,  especially  of  the  spinal 
cord.  In  those  conditions  of  paraplegia  of  the  lower  extremities,  pa- 
ralysis of  the  bladder  and  intestines  occurring  frequently  in  locomotor 
ataxia,  myelitis,  and  similar  diseases,  it  is  especially  useful.  Despite 

*  Wiener  medicinische  Wochenschrift,  xxvii.,  Nos.  36-39. 
fEulenberg's"Realencyclopadie  der  Gesammten  Heilkunde,"  vol.  xv.,  p.  294. 
»     j  Archiv  fUr  kliniscbe  Medizin,  1889-90. 


THE  WARM   FULL  BATH.  243 

the  greatest  care,  bedsores  occur  and  progress  to  serious  proportions 
in  these  cases,  compelling  resort  to  the  continuous  bath,  which  has 
proved  to  be  the  most  effective  remedy  for  this  serious,  discomforting, 
and  painful  trouble.  It  was  during  the  treatment  for  bedsores  that 
Kiess  discovered  with  great  satisfaction  the  most  surprising  results  in 
the  production  of  improvement  and  retrocession  of  organic  nervous 
disease,  such  as  spinal  pains,  excentric  pains  in  the  extremities,  con- 
tractions which  often  rendered  any  position  in  bed  painful,  reflex 
spasms,  and  similar  manifestations. 

The  same  effect  was  noticed  in  chronic  meningitis,  apoplexies  re- 
sulting in  contractions,  and  in  hemiplegia,  tumors  of  the  brain,  etc. 
Besides  the  symptoms  enumerated,  general  hyperaesthesia,  and  espe- 
cially cerebral  excitement  and  delirium,  are  most  favorably  influenced 
by  this  bath. 

Prolonged  submersion  in  water  of  neutral  temperature  exercises  a  • 
calming  effect  upon  the  irritability  of  the  brain,  and  offers  a  basis 
for  favorably  influencing  these  diseases  of  the  nervous  system,  in  which 
therapeutic  efforts  are  usually  so  fruitless.  The  regulation  and  re- 
moval of  peripheral  irritations  probably  explain  these  effects;  the 
theory  of  imbibition  and  succulence  of  the  terminal  nerve  fibres  of  the 
skin  seems  to  be  unnecessary  to  account  for  the  latter.  But  not  alone 
are  the  principal  symptoms  improved  in  these  nervous  diseases ;  in  a 
not  inconsiderable  number  of  cases  the  continuous  bath  appears  to 
exercise  a  directly  beneficial  effect  upon  the  retrocession  of  the  patho- 
logical processes,  as  far  as  this  is  possible.  "  In  about  one-half  of  such 
cases  of  spinal  and  cerebral  organic  diseases,  which  exceeded  one  hun- 
dred in  number  and  which  were  subjected  to  these  baths  for  several 
weeks,  the  improvement,  not  only  of  the  symptoms,  but  in  the  disease 
itself,  was  undeniable,"  says  Kiess.  The  motor  and  sensory  paralyses, 
ataxia,  and  related  symptoms  receded  under  the  baths,  although  they 
had  been  but  slightly  influenced  or  remained  unaffected  under  the  use 
of  other  therapeutic  measures  which  had  been  applied  during  many  pre- 
ceding months.  In  those  cases  in  which  complete  retrocession  was 
possible,  as  in  incipient  inflammatory  conditions  and  in  exudations  capa- 
ble of  absorption,  the  application  of  continuous  baths  apparently  con- 
tributed greatly  to  the  cure.  In  this  manner  are  probably  explicable 
the  cures  of  central  paralyses  which  are  claimed  to  result  at  thermal 
mineral  springs;  indeed  in  many  of  these  a  prolonged  stay  in  the 
warm  piscines  is  prescribed  by  the  resident  physicians  with  good  effect. 

Riess  mentions  a  case  of  compression  myelitis  and  other  cases  of 
desperate  character,  as  illustrations  of  what  may  be  accomplished  by 
these  continued  warm  baths. 

Zuschlag  (loc.  cit.  p.  119)  has  treated  182  cases  of  various  incurable 


244        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

maladies  during  six  years.  He  had  50  cases  of  bedsores  (cases  of  the 
central  nervous  system  and  senile  marasmus),  of  which  43  died,  a 
mortality  due  to  the  nature  of  the  diseases — tabes,  brain  and  spinal 
tumors,  etc.  The  advantage  of  the  water-bed  for  keeping  these  cases 
absolutely  clean  will  be  best  appreciated  by  those  who  have  treated 
such  cases  without  it. 

Inoperable  cancer  of  the  urogenital  tract  with  destruction  of  tissue 
and  fistulas.  For  these  unhappy  creatures  the  water-bed  is  an  inesti- 
mable boon. 

Tuberculosis  of  the  bones  and  joints,  large  abscesses,  suppurating 
wounds,  gangrene,  sejjsis  are  diseases  in  which  the  continuous  bath 
affords  "triumphant  results."  A  case  of  diabetic  gangrene,  which 
had  been  unsuccessfully  amputated  four  times,  was  cured  in  thirty-six 
days'  residence  in  the  water-bed.  Especially  does  Zuschlag  recommend 
the  latter  in  neglected  paraphimoses,  and  artificial  anus,  or  fistuloe, 
fecal  or  urinary,  in  which  he  regards  them  as  a  "great  blessing." 

Extensive  burns  offer  the  most  promising  field  for  the  continuous 
bath.  Hebra  Avas  the  first  to  suggest  this  treatment.  Zuschlag  cell- 
firms  Hebra's  statement.  He  regards  the  greatest  advantage  to  be  not 
the  cure  of  burns  (for  the  third  degree  of  the  latter  are  always  fatal), 
but  the  enormous  relief  they  afford  and  the  rapidity  of  healing  of 
suppurating  burns.  There  is  no  need  of  painful  dressings;  pieces  of 
dead  skin,  etc.,  may  be  easily  removed  with  scissors  without  disturb- 
ing the  sufferer.  Of  ten  cases  of  second  and  third  degrees  of  extensive 
burns  four  were  cured.  All  cases  should  be  subjected  to  the  bath 
before  they  become  exhausted,  if  the  blessings  to  patient  and  attend- 
ants are  to  be  fully  realized. 

The  author  recalls  a  woman  he  treated  in  the  Manhattan  General 
Hospital  for  a  burn  involving  the  entire  body.  Her  agonizing  cries 
filled  the  ward,  despite  large  hypodermics  of  morphia.  A  hammock 
bath  was  extemporized  under  his  direction  by  Dr.  Belnap,  the  house 
physician,  as  follows:  A  stout  sheet  was  laid  into  the  tub.  Stout 
strips  of  bandage  were  secured  on  both  edges  by  safety-pins,  about 
twelve  inches  apart  and  of  sufficient  length  to  reach  beneath  the  tub 
and  be  united  by  tying  or  safety-pins.  On  one  side  the  bandages  were 
short,  on  the  other  long.  The  latter  were  carried  under  the  tub  to 
a  point  on  the  opposite  side,  where  they  were  tied  in  such  manner  with 
the  short  pieces  that  the  sheet  was  lifted  from  the  bottom  of  the  tub 
about  six  inches.  Upon  this  crude  hammock,  suspended  within  the 
bath-tub,  the  agonized  creature  was  placed,  her  head  supported  by  a 
water  pillow,  after  the  tub  had  been  half  filled  with  water  at  98°  F. 
in  which  four  pounds  of  bicarbonate  of  soda  had  been  dissolved.  After 
the  patient  was  in  situ,  the  tub  was  filled  to  the  brim  with  warm 


THE  WARM  FULL  BATH.  245 

water,  and  covered  with  a  blanket.  A  piece  of  hose  attached  to  the 
water  supply  was  led  into  the  tub  near  its  foot  and  a  nurse  stationed 
constantly  to  maintain  the  temperature.  The  patient  was  so  com- 
pletely relieved  that  she  fell  into  a  fitful  slumber,  and  she  continued 
free  from  pain  until  death  released  her  twenty-four  hours  later 

Cystitis. — In  this  disease  the  treatment  by  irrigation  is  much  more 
successful  when  combined  with  the  continuous  bath.  Riess  mentions 
five  distinct  cases,  of  which  three  ended  in  recovery.  Five  cases  of 
obstinate  sciatica  yielded  to  the  continuous  bath.  In  chorea  he  ob- 
tained partial  results.  In  multiple  neuritis  the  pain  was  relieved. 
Anasarca  arising  from  heart  and  kidney  trouble  yielded  especially 
good  results,  although  in  these  cases  there  was  a  decrease  of  urine. 
The  baths  should,  therefore,  not  be  used  when  the  latter  is  scanty. 

In  obstinate  cases  of  articular  and  muscular  rheumatism  in  which 
all  other  treatment  had  failed,  daily  baths  of  twelve  hours'  duration 
afforded  good  results.  In  almost  all  cases  he  obtained  an  improvement 
of  the  general  nutrition. 

Chronic  diarrhoea  seemed  to  improve  decidedly. 

Typhoid  Fever. — For  the  treatment  of  typhoid  and  other  fevers  Dr. 
Riess  also  recommends  the  hammock  bath,  with  an  array  of  statistics 
and  clinical  data  which  demand  careful  consideration.  It  consists  of 
immersing  the  patient  in  a  bath  of  88°  F.  He  advises  that  the  patient 
be  submerged  whenever  the  rectal  temperature  reaches  102°  F.,  and 
that  he  be  allowed  to  remain  in  the  bath  usually  during  the  day  only, 
but,  if  necessary,  day  and  night,  until  his  rectal  temperature  registers 
100°  F.  He  is  then  removed,  and  again  placed  in  the  bath  when  he 
registers  102°  F.  If  the  temperature  falls  too  slowly,  or  rises  in  the 
bath,  an  occasional  short  bath  of  60°  F.  or  a  moderate  dose  of  antipyrin 
was  used. 

This  method  is  certainly  much  more  free  from  trouble  and  more 
agreeable  to  the  patient,  when  he  becomes  accustomed  to  it,  than 
the  cold  bath,  and  may  thus  be  substituted  for  the  latter  in  some  in- 
stances. 

Riess  *  appeals  to  his  clinical  results  in  eight  hundred  and  nine 
cases  treated  in  the  Allgemeines  Krankenhaus  zu  Friedrichshaiu. 
Although  a  mortality  percentage  does  not  prove  much,  because  many 
hospital  cases  could  not  be  saved  by  any  treatment,  he  does  claim  that 
he  can  show  the  lowest  mortality  of  any  hospital  in  the  city,  and  in 
his  own  hospital  the  mortality  has  been  reduced  from  10  per  cent  to 
8.5  per  cent;  12  deaths  were  caused  by  pneumonia,  4  by  hemorrhage, 
and  10  were  uncomplicated.  The  duration  of  his  cases  was  decidedly 
influenced,  ho  claims,  contrary  to  the  accepted  doctrine  with  regard  to 
*  Monograph  of  author,  and  Archiv  filr  klinische  Medicin,  1889-90. 


246       THE   PRINCIPLES  AND  PRACTICE   OF   HYDROTHERAPY. 

the  course  of  typhoid  fever.  Although  most  cases  came  in  after  the 
eighth  day,  the  average  stay  was  17.9,  including  740  cases  that  ended 
in  recovery.  Three  hundred  and  one  cases,  coming  in  before  the  sixth 
day,  remained  fifteen  days ;  the  others,  17.7.  In  341  cases,  which  came 
in  before  the  sixth  day,  the  duration  of  fever  averaged  15.5  days;  399 
cases,  admitted  later,  averaged  19.9  days — certainly  a  much  shorter 
average  duration  than  is  usually  observed  in  so  large  a  number  of 
cases.  Among  the  deaths  there  were  10  uncomplicated,  18  pneu- 
monia, 12  severe  throat  affections,  12  perforations,  3  intestinal  hemor- 
rhage, 3  purulent  pleuritis,  3  chronic  pysemia  during  convalescence, 
and  of  the  remainder  one  each  of  gangrenous  phlegmon,  gangrene  of 
the  lung,  noma,  hemorrhagic  nephritis,  dysentery,  pelvic  tumor,  and 
old  heart  lesion. 

Hence,  only  1.2  per  cent  died  without  some  complication;  34 
per  cent  of  those  dying  were  admitted  before  the  sixth  day  of  ill- 
ness; 65.2  per  cent  after  the  sixth  day — the  average  date  of  the  ad- 
mission of  the  fatal  cases  being,  therefore,  9.5  days  after  inception  of 
illness. 

The  effect  of  this  treatment  upon  individual  symptoms  must  be 
carefully  studied.  Upon  the  cerebral  disturbances  these  prolonged 
baths  seemed  to  act  more  favorably  even  than  short  cold  baths.  If 
this  had  not  been  the  case,  it  would  have  been  impossible  to  detain 
somnolent  and  delirious  or  violent  cases  in  the  bath  without  a  much 
greater  number  of  nurses.  The  fact  was,  however,  that  these  cerebral 
symptoms  receded  without  exception  after  the  first  prolonged  bath  ;  the 
actual  status  typhoidus  disappeared  permanently  on  the  second  or 
third  day. 

Influence  upon  circulation  was  also  favorable.  Only  during  the 
first  quarter-hour  did  the  heart  action  seem  embarrassed,  the  pulse 
becoming  small.  And  this  should  be  remembered,  not  to  discourage 
the  attendant,  because  it  very  soon  becomes  stronger  and  slower. 

Lung  complications  were  never  aggravated,  but  on  the  contrary  were 
improved,  and  rarely  occurred  in  cases  admitted  early.  The  intes- 
tinal lesions,  too,  were  favorably  influenced;  diarrhoeas  diminished  so 
rapidly  that  they  never  interfered  with  the  continuance  of  the  bath. 
Complications  were  diminished.  There  were  only  2.6  per  cent  of  intes- 
tinal hemorrhages,  and  1.6  per  cent  of  perforation  peritonitis;  of 
which  latter  cases  one  ended  in  recovery.  There  were  5.5  per  cent  of 
pneumonia,  2.1  per  cent  of  throat  affection,  and  other  complications  or 
sequelae  were  very  rare.  Only  furuncles  and  subcutaneous  abscesses 
•were  increased  somewhat  (3.4  per  cent). 

Kiess  concluded,  therefore,  and  with  justice,  that  the  treatment 
of  typhoid  fever  by  the  continuous  baths  has  an  especially  favorable 
effect,  because  it  does  not  reduce  the  temperature  rapidly  and  does 


THE  WARM:  FULL  BATH.  247 

diminish  the  severity  of  other  symptoms,  shortens  the  duration  of 
fever,  and  reduces  the  mortality  to  a  low  point.  Bless  furnishes  in 
connection  with  this  essay,  read  before  the  Science  Congress  at  Heidel- 
berg in  September,  1889,  six  temperature  charts,  which  graphically 
illustrate  the  method  and  its  results.  I  select  one  of  these,  giving 
the  temperature  and  duration  of  baths  and  remissions. 

Siefke,  a  nurse,  aged  twenty -nine  years,  became  ill  in  the  hospital ; 
he  had  continuous  baths  from  the  second  to  the  eighth  day,  after  which 
he  was  normal.  He  was  put  into  the  bath  with  a  rectal  temperature 
of  39.2°  C.,  and  remained  in  it  fourteen  hours;  when  his  temperature 
reached  36.4°  he  was  removed.  In  four  hours  the  temperature  rose  to 
39.4° ;  he  was  put  into  bath  for  ten  hours  and  removed  at  37.2°.  In 
four  hours  it  reached  39° ;  after  eight  hours  in  the  bath  it  was  37°. 
After  three  hours  out  of  the  bath  it  registered  38.8°;  a  bath  of  nine 
and  one-half  hours  brought  it  to  37.8°.  Out  of  the  bath  for  an  hour  it 
rose  to  38.6° ;  a  bath  of  ten  hours  reduced  it  to  37°.  After  three  hours 
it  rose  to  39°;  a  ten-hour  bath  brought  it  down  to  37.2°.  After  six 
hours'  it  rose  to  39° ;  an  eight-hour  bath  reduced  it  to  37.4°.  In  three 
hours  it  rose  to  39C ;  an  eight-hour  bath  reduced  it  again  to  37.4°.  In 
four  hours  it  rose  to  38.6° ;  he  was  now  kept  in  the  bath  for  twenty -two 
hours,  at  the  end  of  which  time  the  temperature  fell  to  37°.  He  was 
removed  for  four  hours,  and  the  temperature  rose  to  38.8°.  In  the 
bath  eight  hours,  it  fell  to  37.4°;  out  four  hours  it  rose  to  38.8°.  In 
the  bath  six  hours,  it  fell  to  37°,  after  which  it  remained  normal  on 
the  eleventh  day. 

This  method  of  bathing  presents  many  advantages,  if  it  can  be 
carried  out.  Its  superiority  over  the  Brand  bath  lies  in  (1)  its  abortive 
power,  for  that  it  certainly  shortens  the  disease  is  proven  by  three  of 
the  cases;  being  in  nurses  and  servants  residing  in  the  hospital,  the 
beginning  and  ending  of  the  fever  could  be  positively  determined; 
(2)  in  its  being  less  heroic  and  disturbing  and  more  comfortable.  Its 
inferiority  to  the  Brand  method  lies  in  the  fact  that  its  mortality  is  far 
above  that  of  the  latter.  This  objection  may  be  more  apparent  than 
real.  There  is  certainly  quite  a  difference  between  cases  of  poor  people 
entering  a  civil  hospital,  usually  after  many  days  of  bootless  treatment 
or  neglect  at  home,  and  the  average  robust  soldier  entering  a  military 
hospital  almost  immediately  after  being  pronounced  unfit  for  duty. 

I  am  disposed  to  believe,  from  the  experience  of  Brand,  Vogl,  Jilr- 
gensen,  Wilson,  and  my  own,  that  of  the  "  thirty-four  of  those  dying 
who  had  been  admitted  before  the  sixth  day  of  illness  "  most,  if  not 
all,  would  have  been  saved  by  strict  cold  bathing;  and  a  large  propor- 
tion of  the  other  cases  (averaging  less  than  ten  days  ill  when  admitted) 
might  have  been  saved.  Still  the  results  are  so  far  better  than  those 
of  the  fatal  expectant  treatment  that  it  would  seem  ungrateful  to  this 


248        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

courageous  and  original  clinician  to  cavil  at  the  excellent  method,  which 
he  has  again  advocated  in  a  recent  article.*  In  the  latter  Biess  shows 
that  in  the  large  number  of  cases  treated  by  a  less  decided  execution 
of  his  method,  the  average  mortality  taken  for  ten  years  has  risen 
three  per  cent  in  the  same  hospital.  He  claims  that  the  excretion  of 
nitrogen  is  increased  by  these  baths,  while  antipyrin  diminishes  it. 

The  observations  of  Bless  have  been  confirmed  by  Dr.  Barr,  of 
Liverpool,!  whose  mortality  in  fifty-five  successive  cases  was  only  one. 
Barr  treated  twenty-five  of  his  cases  by  continuous  immersion  in  water 
at  93°,  when  their  body  temperature  was  100°  or  over;  the  water  tem- 
perature was  raised  as  the  patient's  temperature  approached  the  nor- 
mal. Although  this  is  a  very  small  experience,  it  offers  confirmation 
of  the  value  of  the  hammock  bath  in  typhoid  fever. 

Kraepelin,  the  eminent  psychiatrist  of  Heidelberg,  regards  the  con- 
tinuous bath  (98°  to  100°)  for  several  hours  as  the  most  effective  calm- 
ative, inasmuch  as  it  often  succeeds  when  medicinal  agents  fail. 
(See  article  Insanity.) 

In  subacute  nephritis  a  bath  of  95°  to  100°  F.,  with  gentle  friction 
over  the  entire  body  and  occasional  bathing  of  the  face  and  head  with 
water  at  50°  or  60°  F.  to  counteract  possible  cardiac  enfeeblement  and 
loss  of  arterial  tension,  and  continued  for  half  an  hour  or  an  hour,  offers 
the  most  useful  therapeutic  resource  at  the  physician's  command,  if 
followed  by  rest  in  bed  and  milk  or  other  salt- free  diet.  The  author's 
clinical  observations  are  amply  confirmed  by  the  investigations  of 
Strasser  and  Wolf  of  Vienna.  In  the  literature  of  nephritis  the  favor- 
able effects  of  so-called  lukewarm  baths  of  a  few  minutes'  duration 
are  often  referred  to  and  explained  upon  the  theory  that  they  enhance 
cutaneous  activity.  In  recent  years  the  significance  of  albuminuria  as 
a  manifestation  in  nephritis  has  diminished,  while  more  emphasis  is 
placed  upon  renal  insufficiency  in  the  elimination  of  nitrogen,  chlor- 
ides, and  water.  The  result  of  this  more  practical  and  broader  view 
has  been  a  more  intelligent  regulation  of  the  hygienic  environment  of 
the  patient  and  of  his  diet.  Numerous  experiments,  conducted  by 
Strasser  and  Wolf  with  and  without  baths,  have  demonstrated  that  in 
patients  subjected  to  methodical  bathing  there  was  a  decided  increase 
of  urine,  frequently  a  positive  increase  of  nitrogen  and  chloride  of 
sodium  excretion,  the  latter  sometimes  being  threefold,  and  continuing 
after  the  baths.  The  excretion  of  albumin  was  reduced  in  percentage, 
but  the  absolute  quantity  was  not  much  larger.  There  never  was  a 
retention  of  N  or  NaCl  products  on  the  bath  days,  either  in  the 
intense  cases  with  oedema  or  in  the  milder  ones.  In  a  severe  case  with 
redema  a  few  days'  bathing  increased  diuresis  and  chloride  excretion 

*  Deutsche  med.  "Wochenschrift,  1899,  p.  655. 

f" Treatment  of  Enteric  Fever,"  London,  H.  K.  Lewis,  1892. 


THE   WARM    FULL   BATH.  249 

and  removed  the  oedema.  It  was  remarkable  that  this  result  was  ob- 
tained under  ordinary  diet  containing  an  abundance  of  N  and  NaCl. 
The  benefit  claimed  by  the  modern  method  of  depriving  the  system  of 
NaCl  was  attained  by  the  simple  warm  bath.  That  the  effect  is 
very  decidedly  enhanced  by  a  diet  free  from  NaCl  has  been  demon- 
strated by  the  later  observations  of  Strasser  and  Blumenkranz,*  who 
made  some  interesting  experiments,  which  confirm  the  earlier  find- 
ings. The  bath  temperature  should  be  maiutained  at  about  95°  F., 
unless  the  patient  feels  chilly,  and  in  acute  cases  the  patient  should 
lie  in  a  hammock  or  on  a  cushion  in  the  bath  for  an  hour;  iu  the 
subacute  or  chronic  case  he  may  sit  erect  in  the  warm  water  reach- 
ing to  his  neck.  If  the  tub  is  covered  with  a  blanket  the  water 
temperature  may  easily  be  maintained  by  the  inflow  of  hot  water. 
The  bed  should  be  warmed  while  the  patient  is  in  the  bath,  from 
which  he  is  removed  at  the  expiration  of  an  hour,  wrapped  in  warm 
(not  hot)  sheets.  He  need  not  be  dried,  but  may  remain  quiescent 
for  one  or  two  hours.  Two  baths  each  day  are  advisable.  They 
found  in  genuine  nephritis  a  very  pronounced  and  often  considerable 
increase  of  diuresis  and  elimination  of  all  products  of  tissue  change 
on  the  bath  days.  This  effect  continued  for  several  hours  and  days. 
Although  they  recognize  the  influence  of  the  bath  on  the  renal  circula- 
tion they  are  disposed  to  regard  the  favorable  changes  iu  the  elimina- 
tion of  water,  salt,  and  nitrogen  as  an  expression  of  a  real  enhance- 
ment of  the  functionating  capacity  of  the  kidney,  viz.,  that  the  bath 
relieves  the  renal  insufficiency.  That  the  increase  of  K  and  salt  elim- 
ination is  not  the  result  of  increased  diuresis  is  disproved  by  one  of 
the  experiments  in  which  these  occurred  without  augmented  diuresis, 
and  continued  for  three  days  without  additional  baths.  The  influence 
of  these  baths  upon  albumin  in  the  urine  varied  so  considerably,  some- 
times increasing,  and  again  diminishing,  that  this  question  must  be 
left  open  until  larger  data  are  obtainable.  The  cedematous  manifesta- 
tions of  nephritis  are  favorably  influenced  by  these  baths.  Strasser 
and  Wolf  claim  that  these  have  been  confirmed  by  colleagues  who  have 
followed  their  method  of  combining  a  diet  free  from  salt  with  the  pro- 
longed bath  of  a  neutral  temperature.  In  ursemic  cases  this  simple 
procedure  is  surely  worthy  of  a  fair  trial.  One  or  two  baths  suffice; 
when  they  were  applied  more  frequently  or  their  duration  was  pro- 
longed, the  patients  complained  of  debility  and  headache  without  an 
improvement  in  the  excretions.  The  author  has  dwelt  upon  these  ex- 
periments and  observations  somewhat  fully  because  he  is  personally 
acquainted  with  Dr.  Strasser  and  recognizes  his  ability  and  sincerity. 
Moreover,  his  own  observation  has  so  often  convinced  him  of  the 
hopelessness  of  medicinal  management  of  these  desperate  cases  that 

*  Blatter  f  ilr  Idinische  Medizin,  May,  1907. 


250       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 


he  regards  the  application  of  the  neutral  prolonged  bath  as  an  im- 
portant therapeutic  addition,  which  demands  adoption  by  the  general 
practitioner. 

LOCALIZED  CONTINUOUS  BATHS. 

Technique. — In  domestic  practice  a  deep  pan  may  be  extemporized. 
Dr.   Frank  Hamilton,  of  Bellevue  Hospital,  who  was  an  enthusiastic 
advocate  of   the  submer- 
sion treatment  of    surgi- 
cal cases,  devised  an  ap- 
paratus which    affords    a 
neat    and    comfortable 
method  of   applying   hot 
water  continuously  to  the 
extremities. 

Fig.   48    represents   a 
bath    for   the   upper   ex-  FIG.  48. 

tremities. 

For  the  lower  extremities  (Fig.  49)  a  zinc  bath  is  used  also,  some- 
what larger,  the  floor  being  in  the  form  of  an  inverted  roof,  the  apex 
of  which  is  below ;  the  base  being  represented  by  the  open  top  of  the 
bath;  this  latter  is  also  provided  with  a  movable  cover.  The  apex  is 
supported  by  a  wooden  frame  and  horizontal  board.  This  bath  is,  like 
the  arm  bath,  provided  with  pins  for  suspension  of  the  limb  and  with  a 
stop  cock. 


FIG.  49. 


In  the  case  of  the  foot  bath,  when  it  is  found  uncomfortable  to  pro- 
ject the  foot  from  the  side  of  the  bed,  the  portion  of  the  bed  upon  which 
the  body  reposes  is  elevated  by  mattresses,  and  the  bath  is  placed  on 
the  uncovered  foot  of  the  bedstead. 

The  water  should  be  kept  at  such  a  temperature  as  to  feel  warm  to 
the  hand  of  the  attendant,  and  this  is  found  to  be  about  95°  F.  Suffi- 


THE  WARM   FULL   BATH.  251 

cient  uniformity  has  been  attained  generally  by  changing  the  water 
three  times  daily. 

Antiseptics  may  be  added  to  these  baths  and  thus  prevent  the 
occurrence  of  sepsis,  which  is  so  frequent  in  lacerated  wounds. 

Therapeutic  Indication — Erysipelas. — Dr.  Achilles  Rose  relates* 
cases  of  erysipelas  treated  by  the  continuous  warm  bath,  showing  the 
powerful  effect  of  the  warm  bath  on  this  infectious  inflammation,  how 
the  temperature  was  thereby  promptly  reduced,  and  how  the  whole 
course  of  the  disease  at  once  changed  for  the  better. 

Polyarthritis. — Hueter  recommends  in  polyarthritis  synovialis  acuta 
(rheumatismus  articulorum  acutus),  after  the  acute  stage  has  passed, 
and  also  in  polypanarthritis  (arthritis  deformans),  therapeutics  which 
aid  absorption  and  excite  circulation,  and  praises  as  the  best  means  to 
this  end  permanent  warm  baths,  either  for  arm  or  leg,  in  tubs  of  proper 
size  and  shape,  or  general  baths,  as  the  case  may  require.  He  states 
that  this  therapeutic  measure  in  polyarthritis  synovialis  chronica,  as 
well  as  in  polypanarthritis,  has  not  been  surpassed  by  any  other  method 
of  treatment. 

Recent  Wounds. — When  secondary  hemorrhage  is  at  all  liable  to 
occur,  the  limb  is  dressed,  according  to  Dr.  Hamilton,  for  a  few 
hours  with  either  warm  or  cold  fomentations,  and  is  left  reposing 
in  bed;  but  neither  sutures,  adhesive  plasters,  nor  bandages  are 
applied.  At  the  expiration  of  this  time  either  the  bath  or  the 
warm-water  fomentations  are  commenced,  and  thereafter  employed 
systematically.  The  patient  is  at  liberty  at  any  time  to  lift  the  limb 
from  the  bath,  and  he  generally  does  this  pretty  often,  to  see  how  it 
is  progressing. 

Warm-water  fomentations  are  regarded  by  Hamilton  always  second 
in  value  to  submersion  in  the  prevention  and  cure  of  inflammation,  and 
they  are  reserved,  therefore,  for  those  examples  in  which  submersion 
for  one  or  another  reason  cannot  properly  be  employed. 

Fomentations  are  to  be  employed  after  the  fourteenth  day  in  all 
those  cases  in  which  submersion  was  used  at  first ;  occasionally  when 
the  patient  is  weary  of  the  confinement  of  the  bath,  the  limb  is  taken 
out  and  fomented  during  the  night. 

"No  treatment  hitherto  adopted,"  says  Dr.  Hamilton,  "under  our 
observation,  has  been  attended  with  equally  favorable  results. 

"  The  phenomena  usually  observed  in  cases  of  recent  lacerated  or 
incised  wounds,  when  submerged,  are  a  sense  of  comfort,  yet  not  abso- 
lute relief  from  pain.  On  the  second  or  third  day  the  parts  adjacent 
are  swollen  but  not  much  reddened ;  the  integument  generally  assumes 
a  white  and  sodden  appearance,  and  with  only  slight  tenderness.  On 
the  fifth,  sixth,  or  seventh  day  the  swelling  is  greater  than  usually 

*  Medical  Record,  1893. 


252        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

accompanies  other  plans  of  treatment,  and  with  the  inexperienced  is 
likely  to  excite  alarm ;  but  it  is  found  not  to  be  attended  with  increased 
tenderness,  and  it  pits  under  pressure,  showing  that  it  is  a  condition 
of  oedema  chiefly.  At  this  time  the  granulations  are  generally  covered 
with  lymph,  or  some  exudate  of  a  whitish  color,  which  might  easily 
be  mistaken  for  a  diphtheritic  deposit.  At  the  end  of  fourteen  days 
or  thereabouts  (the  period  at  which  in  most  cases  we  substitute  fo- 
mentation for  submersion)  the  limb  is  still  cedematous  and  the  granula- 
tions are  abundant,  sometimes  presenting  a  fresh  red  appearance,  and 
at  others  covered  with  the  white  exudate." 

Position  of  Injury. — The  lower  extremities  can  be  completely  and 
permanently  submerged  only  to  a  point  three  or  four  inches  below  the 
knee,  and  the  upper  extremities  to  a  point  a  few  inches  above  the 
elbow ;  consequently,  submersion  is  limited  to  those  portions  of  the  ex- 
tremities which  are  below  the  points  mentioned. 

Character  of  Injury. — Submersion  in  warm  water  demonstrates  its 
superiority  over  other  plans,  especially  in  the  case  of  a  laceration  or 
contusion  of  the  hand  or  of  the  foot,  when  the  integument  and  flesh 
are  extensively  torn — provided  the  limb  is  submerged  without  closing 
the  wound — that  is,  without  sutures  or  bandages ;  indeed,  sutures  are 
inadmissible  when  this  plan  is  adopted,  since  the  oedema,  which  almost 
inevitably  ensues,  would  break  away  the  sutures. 

Mere  contusions,  without  external  lesions,  have  been  treated  almost 
constantly  at  St.  Francis'  Hospital  by  this  method;  and  the  results 
have  been  in  all  cases  satisfactory,  and  occasionally  they  have  pro- 
gressed toward  recovery  in  a  manner  to  excite  surprise." 

These  observations  on  localized  continuous  baths  are  reproduced 
in  order  to  demonstrate  the  flexibility  of  water  as  a  remedial  agent. 
Their  efficiency  will  even  in  the  present  aseptic  area  of  surgery  bear 
favorable  comparison  with  modern  methods  in  the  promotion  of  clean- 
liness and  asepsis  of  lacerated  wounds. 

In  severe  sprains  Professor  Keclus,  of  Paris,  finds  after  trying  all 
other  methods  that  the  best  results  are  obtained  by  plunging  the  joint 
into  warm  water  and  gradually  raising  the  temperature  of  the  latter  to 
118°  and  as  far  as  130°  F.,  according  to  the  patient's  tolerance.  The 
bath  is  continued  for  ten  minutes,  when  the  joint  becomes  red,  the 
vessels  become  engorged,  and  pain  and  tenderness  disappear.  The 
absorption  of  blood  and  lymph  is  so  much  facilitated  that  subsequent 
massage  becomes  more  effective.  The  bath,  followed  by  massage  and 
a  rubber  bandage,  may  be  repeated  morning  and  evening  with  great 
advantage. 

These  practical  observations  of  well-known  physicians  and  sur- 
geons on  a  method  of  treatment  which  is  valuable  but  not  sufficiently 
appreciated  may  induce  the  reader  to  apply  it  in  appropriate  cases. 


CHAPTER   IX. 
THE  DOUCHE. 

MOST  of  the  hydriatrie  procedures  hitherto  described  demanded  the 
aid  of  an  assistant,  whose  hands  applied  the  water  directly  to  the  body. 
The  douche  is  the  only  procedure  in  which  a  mechanical  effect  is 
brought  about  without  direct  intervention  of  a  second  person,  who  is 
replaced  by  the  force  derived  from  atmospheric  pressure.  It  is  applied 
by  means  of  a  rubber  hose,  which  at  its  proximal  end  is  connected 
with  the  water  supply,  and  to  which  at  its  distal  portion  is  attached  a 
nozzle,  which  may  be  supplied  with  tubes  ranging  from  one  sixteenth 
to  one  inch  in  diameter.  A  variety  of  douches  may  thus  be  produced ; 
the  fine  or  coarse  jet  douche  or  the  fan  douche.  The  latter  is  formed 
by  placing  the  index  finger  of  the  hand  holding  the  nozzle  upon  the 
upper  border  of  the  outlet,  producing  an  expansion  of  the  otherwise 
solid  jet  into  a  fan-shaped  stream,  which  is  played  upon  the  patient 
like  a  broad  water  brush  or  fan.  The  jet  and  fan  douche  are  the 
douches  mobiles  of  the  French.  The  Scotch  douche  consists  of  alternat- 
ing streams  of  hot  and  cold  water,  directed  upon  the  patient,  usually 
on  the  affected  parts,  i.e.,  localized  over  them,  as  in  sciatica  and  syn- 
ovitis.  Steam  of  low  pressure  is  sometimes  used  instead  of  hot  water. 
It  must  be  remembered  that  steam  will  scald  if  not  entirely  free  of 
water  particles.  The  patient  should  stand  at  eight  feet,  and  gradu- 
ally approach  the  nozzle  until  he  feels  the  hot  steam  uncomfortably. 
The  steam  Scotch  douche  is  rendered  somewhat  difficult  by  the  fact 
that,  while  the  cold  water  is  applied  at  a  distance  of  eight  feet,  the 
steam  is  ineffective  at  this  distance  and  the  patient  is  therefore  re- 
quired to  move  nearer,  and  then  advance  for  the  cold  water.  The  al- 
ternations of  temperature  are  made  in  accordance  with  the  case.  Heat 
is  applied  longer  than  cold.  Beginning  with  thirty  seconds  of  the 
former  and  twenty  of  the  latter,  a  few  seconds  are  added  with  each 
alternation,  until  one  to  five  minutes  have  been  consumed.  The  pro- 
cedure is  usually  terminated  by  a  cold  fan  douche  over  the  entire  body. 
The  douche-table  devised  by  the  author  is  provided  with  an  independ- 
ent mechanism  for  the  Scotch  douche  and  with  a  steam  supply.  The 
latter  should  be  allowed  to  flow  until  it  issues  quite  free  of  water. 
Other  forms  of  the  douche  are  the  rain  douche,  commonly  known  as 


254       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

the  shower  bath,  which  issues  from  a  rose  a  few  feet  above  the  patient 
(the  reservoir  supplying  it  being  elevated  fifty  or  sixty  feet) ;  the  cir- 
cular bath  or  douche,  commonly  known  as  the  needle  bath;  the  as- 
cending douche,  applied  upon  the  lower  part  of  the  body  from  below, 
in  the  sitting-posture. 

They  are  directed  upon  the  patient  standing  about  eight  or  ten  feet 
from  the  nozzle.  The  doucheur  must  hold  the  nietal  portion  of  the 
hose,  in  order  to  obtain  quick  knowledge  of  change  of  temperature  in 
the  water. 

The  stationary  douches  are  in  great  favor  in  Germany,  where 
the  douche  mobile  is  not  so  popular.*  The  modern  douche  utilizes  all 
mechanical  contrivances  by  which  water  may  be  delivered  under  more 
or  less  atmospheric  pressure  from  a  reservoir,  which  in  cities  feeds 
the  ordinary  water  supply  or  into  which  it  has  been  pumped.  It 
may  be  furnished  with  pressure  also  by  steam  or  hot-air  pumping- 
apparatus. 

The  French  have  improved  this  hydriatric  procedure,  and  really 
have  made  it  the  chief  among  all  their  applications.  Charcot's  name 
is  well  known  as  connected  with  this  application,  because  his  phe- 
nomenal success  in  utilizing  the  valuable  knowledge,  acquired  by  his 
countryman  Fleury  and  others,  in  this  branch  of  the  art,  has  added 
to  the  great  fame  he  has  justly  acquired  as  a  diagnostician  and  prac- 
tical neurotherapist.  Charcot's  douche  is  really  a  jet  douche  applied 
to  the  spine,  and  Fleury' s  douche  consists  of  the  shower  and  jet 
douches  combined. 

Hydrotherapy  is,  as  the  French  represented  by  Duval,  who  is  the 
most  voluminous  author  on  the  subject,  term  it,  a  perturbating  action. 
The  disturbing  effect,  produced  by  the  more  or  less  violent  impinge- 
ment of  water  upon  the  skin,  is  due  to  the  same  elements  which  in 
other  procedures  have  been  shown  as  necessary  for  the  evoking  of 
reaction,  viz.,  the  mechanical  and  thbrmic.  The  mechanical  effect  is 
enhanced  by  the  height  from  which  the  stream  falls  and  the  size  of 
the  outlet.  It  depends  upon  the  pressure  under  which  the  water  is 
delivered,  upon  the  size  of  the  stream,  and  upon  the  distance  of  the 
patient  from  the  attendant. 

The  douche  filiforme  of  Lauriat  is  a  pump  supplied  with  an  arrauge- 

*In  the  Archiv  fur  Balneologie  und  Hydrotherapie,  No.  2,  1897,  Miiller 
furnishes  one  reason  for  the  neglect  of  douches  in  Germany  in  the  fact  that 
the  apparatus  for  administering  them  in  most  hydrotherapeutic  establish- 
ments is  very  imperfect.  "  Whosoever  would  compare  the  douche  to  the 
'  Guss, '  which  reminds  one  unpleasantly  of  the  theological  water  cure,  should 
study  the  technical  arrangements  of  a  French  institution.  From  America 
also  have  recently  come  some  descriptions  of  apparatus  which  show  great 
progress. " 


THE   DOUCHE.  255 

ment  for  great  pressure,  and  connected  with  the  finest  possible  outlet 
tube.  That  this  fine  stream  may  be  made  to  penetrate  the  skin  and 
produce  destruction  of  tissue  and  consequent  bleeding,  the  author  has 
frequently  demonstrated.  This  hydriatic  toy  is  not  so  useful  as  a 
therapeutic  means  as  it  is  for  the  demonstration  of  the  fact  that 
strong  pressure  may  endow  a  stream  of  water  with  destructive  power 
equal  to  the  actual  cautery.  In  proportion  to  the  pressure  applied  we 
obtain  an  erythematous  redness  like  that  produced  by  a  mustard 
plaster,  or  the  destructive  effect  referred  to.  This  affords  evidence 
of  the  great  flexibility  of  this  hydriatric  procedure.  The  latter  is 
enhanced  by  the  thermic  effect,  which  again  affords  great  latitude  by 
reason  of  the  varied  temperatures  which  may  be  used.  In  this  respect 
the  douche  differs  from  other  procedures.  It  may  be  administered  at 
a  lower  temperature  than  the  latter,  because  the  mechanical  effect, 
being  simultaneous,  promotes  reaction  and  thus  furnishes  the  most 
stimulating  of  all  hydriatric  applications. 

Here,  too,  the  law  referred  to  above  is  fully  exemplified,  viz.,  the 
colder  the  water  and  the  more  brief  its  application,  the  more  complete 
the  reaction.  As  we  are  enabled  by  the  douche  to  overcome  the  para- 
lyzing effect  of  any  low  temperature  by  the  stimulus  of  the  mechanical 
effect,  we  possess  in  this  procedure  a  most  powerful  therapeutic  weap- 
on. This  explains  the  great  success  of  the  French  with  the  douche. 

There  are  other  advantages  connected  with  it.  The  brevity  of  its 
application,  which  should  never,  at  low  temperatures  (below  55°),  ex- 
ceed one  minute,  and  should  usually  occupy  only  from  ten  to  thirty 
seconds,  upon  any  one  part,  saves  much  time  and  renders  it  much  less 
disagreeable.  The  cold  water,  not  reaching  the  entire  body  at  once, 
does  not  produce  a  painful  impression,  as  would  be  the  case  were  the 
individual  immersed  in  a  tub  of  water  at  the  same  temperature.  The 
rosy  hue  of  the  skin,  which  frequently  ensues  immediately  upon  the 
impingement  of  the  douche,  indicates  at  once  that  the  chief  end  of 
hydrotherapy  is  being  evoked,  viz.,  reaction. 

Rationale. — The  rationale  of  the  douche  may  be  explained  upon  the 
general  principles  laid  down  in  the  first  part  of  this  work.  There  is 
an  enhancement  of  the  mechanical  effect  produced  by  the  percussion 
and  vibratory  influence  of  a  stream,  which,  being  more  or  less  divided, 
impinges  in  rapid  succession  upon  different  parts  of  the  surface.  This 
active  thermic  irritation  arouses  the  vasomotor  system  more  energet- 
ically than  do  other  forms  of  bathing. 

It  is  not  necessary  to  dwell  upon  the  fact  that  every  physiological 
indication  is  fulfilled  by  the  douche.  The  nerve  centres  are  aroused, 
the  respiration  is  deepened,  the  circulation  is  invigorated,  the  secre- 
tions are  increased. 


256        THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

The  local  action  of  the  douche  is  also  valuable.  It  is  practically  a 
thermic  massage.  It  excites  intensely  the  neuro-vascular  structures; 
hence  it  is  an  admirable  sorbefacient  of  pathological  products.  In  the 
form  of  the  Scotch  douche,  which  consists  of  alternating  streams  of 
hot  and  cold  water,  it  is  especially  applicable  for  this  purpose.  Its 
effects  are  enhanced,  as  in  other  procedures,  by  preceding  applications 
of  warmth,  with  or  without  moisture.  The  French  are  fond  of  using 
the  hot-air  box  bath ;  the  Germans  prefer  the  dry  pack,  by  which  the 
sensitiveness  of  the  skin  is  enhanced,  as  in  other  procedures,  and  with 
it  the  reactive  capacity — auxiliaries  which  will  be  referred  to  later. 

By  variations  of  temperature  and  pressure,  by  changing  the  aper- 
ture of  the  nozzles,  by  increasing  the  number  and  form  of  the  streams, 
as  in  the  spray  and  fan  douche  and  rain  bath,  the  mechanical  effect 
may  be  as  materially  modified  as  the  thermic  effect  may  be  by  in- 
creasing or  reducing  the  temperature  of  the  water.  The  experiments 
of  Maggiora  and  Vinay*  show  clearly  that  hydriatic  procedures  exert 
a  very  considerable  influence  upon  the  muscular  system  by  reason  of 
their  thermic  and  mechanical  effects;  that  cold  chiefly  produces  an 
enhancement  of  muscular  power ;  that  warm  applications  diminish  the 
latter  if  they  are  not  combined  with  mechanical  irritation.  A.  rain 
douche  of  50°  F.,  under  a  pressure  of  two  atmospheres,  increases  three- 
fold the  sum  of  work  the  muscles  are  capable  of  doing.  The  Scotch 


After  Fatigue.  After  Douche. 

FIG.  50.— Fatigue  Curve  after 

Warm  Bath  following  Mus-  Fio.  51.— Fatigue  Curve  before  and  after  Warm 

cular  Fatigue.  Douche  following  Fatigue. 

douche,  oscillating  between  98°  and  53°,  doubles  the  capacity  of  the 

muscles.     Even  douches  of  tepid  water  enhance  the  power  of  resisting 

fatigue  in  the  muscles  and  increase  the  actual  work  which  muscles 

*  Detailed  in  Blatter  fur  klinische  Hydrotherapie,  January,  1892. 


THE   DOUCHE. 


257 


are  capable  of  doing,  while  a  tub  bath  of  the  same  temperature  is 
without  decided  effect.      This  is  graphically  shown  by  the  "  fatigue 
curves"    (Figs.    50 
and  51). 

A  hot  rain  douche 
a  d  m  i  n  i  s  tered  at 
106°  F.  for  ninety 
seconds  produces  a 
disagreeable  sensa- 
tion, to  which  the 
patient  soon  be- 
comes accustomed; 
there  ensues  a  less 
pronounced  e  ff  e  c  t 
upon  the  muscular 
capacity  than  from 
the  fan  douche, 
p  r  o  b  ably  because 
the  latter  impinges 
upon  every  part  of 
the  body  succes- 
sively, while  the  former  strikes  only  the  upper  part  of  the  body  from 
above.  It  is  clear  that  the  mechanical  effect  of  the  douche  compen- 


Normal. 


After  Douche. 


After  Ten  Minutes' 
Massage. 

Fio.  52.— Fatigue  Curve  before  and  after  Cold  Douche. 


FIG.  53.— Fatigue  Curve  of  the  Left  Hand  after  a  Rain  Douche  (Shower  Bath),  60°  F., 
under  pressure  of  two  atmospheres. 

sates  for  the  loss  of  muscular  capacity  arising  from  warm-water  ap- 
plications. Thus  far  the  experiments  have  shown  only  the  enhance- 
ment of  muscular  capacity.  The  effect  of  the  douche  upon  muscles 
already  fatiyued  has  also  been  investigated  by  Yinay  and  Maggiora 
17 


258       THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 


FIG.  54.— Fatigue  Curve  of  the  Right  Hand  after  Rain 
Douche,  98°  F. 


in  a  later  work.*  In  this  series  of  observations  the  individual's  nor- 
mal curve  was  first  taken.  He  was  then  subjected  for  five  or  ten 
minutes  to  severe  muscular  exertion,  after  which  the  "  fatigue  curve" 
was  again  registered.  Now  a  douche  was  administered  and  the  curve 

was  again  noted. 
How  effective  a  cold 
douche  is  for  the 
purpose  of  counter- 
acting fatigue  is 
well  shown  by  the 
subjoined  diagrams 
(Figs.  52,  53,  54). 

All  these  experi- 
ments demonstrate 
clearly  the  rationale 
of  the  douche  in 
that  the  pressure 
under  which  it  is 
delivered  adds  a 
powerful  element  which  is  absent  in  most  other  hydriatric  procedures. 
The  diagrams  Figs.  50  and  51  show  the  inefficiency  of  the  warm 
bath  as  a  restorative,  and  the  value  of  the  douche  for  this  purpose. 
It  will  be  noted  that  the  mechanical  irritation  produced  by  the 
douche  endows  even  warm  water  with  capacity  to  restore  a  fatigued 
muscle. 

Figs.  51  and  52  illustrate  the  difference  of  effect  upon  muscular 
power  between  the  cold  and  hot  douche.  9 

These  experiments  were  made  with  the  ergograph  of  Mosso,  which 
registered  the  muscular  resistance  automatically. 

We  have  thus  a  basis  for  the  well-known  refreshing  and  invigorat- 
ing effect  of  the  douche,  which  in  France  is  so  advantageously  resorted 
to  by  men  and  women  of  feeble  muscular  fibre,  by  people  who  lead 
sedentary  lives  or  lose  their  vigor  in  the  whirl  of  fashionable  dissipa- 
tion. To  endow  feebly  muscled  children  and  youths  with  strength,  to 
invigorate  the  lax  fibre  of  those  men  and  women  who  have  neither  time 
nor  inclination  to  indulge  in  normal  exercise  in  the  open  air,  there 
is  certainly  no  measure  more  valuable  than  the  cold  douche,  carefully 
adapted  to  each  individual  in  duration,  temperature,  and  pressure.  I 
do  not  refer  here  to  diseased  conditions,  but  simply  to  abnormal  feeble- 
ness of  muscle  and  the  incapacity  for  normal  work.  The  full  corrob- 
oration  of  these  views  by  so  scientific  and  exact  an  observer  as  Dr. 

*  Blatter  fur  klinische  Hydrotherapie,  June,  1893. 


THE   DOUCHE.  259 

W.  B.  Oliver  *  is  interesting  and  may  arouse  attention  to  a  method 
of  bathing  which  possesses  much  value.  Dr.  Oliver  says :  "  The  in- 
fluence of  temperature  per  se  is  greatly  modified  by  the  mechan- 
ical agency  of  percussion  and  vibration,  so  that  when  the  water  is 
divided  into  innumerable  fine  jets,  which  impinge  at  different  times 
over  the  entire  surface,  or  when  it  is  applied  in  the  form  of  a  travelling 
douche  accompanied  by  a  vibratory  form  of  massage,  the  vasoinotor 
system  is  much  more  powerfully  affected  than  by  any  form  of  still 
bathing.  The  therapeutic  advantages  of  this  form  of  cold  bathing  are 
very  considerable,  for  it  can  be  made  to  furnish  all  the  tonic  effects 
of  cold  bathing  along  with  an  agreeable  temperature  that  may  be 
adapted  to  individual  requirements.  A  most  intelligent  appreciation 
of  the  curative  value  of  this  and  similar  forms  of  tonic  bathing  now 
prevails  at  many  health  resorts,  where  in  times  gone  by  a  course  of 
bathing  simply  meant  soaking  in  hot  water  with  the  consequent  impair- 
ment of  the  vasomotor  mechanism.  The  massage  douche  and  needle 
bath  is  the  form  of  bathing  best  adapted  to  counteract  the  enervating 
effects  of  city  life,  with  all  its  attendant  worries  and  anxieties,  and 
were  it  established  in  our  large  centres  it  would,  I  am  persuaded,  prove 
to  be  a  boon  to  many  sufferers  from  nervous  exhaustion,  and  would 
become  even  more  popular  and  valuable  than  the  Turkish  bath." 

The  Scotch  douche,  which  consists  of  more  or  less  rapidly  alternat- 
ing streams  of  hot  and  cold  water  played  upon  the  same  part,  is 
applied  for  the  purpose  of  enhancing  the  temperature  effect  of  the 
douche.  Its  effects  upon  the  healthy  organism  have  received  special 
study  in  Russia,  the  results  of  which  are  summarized  by  Professor 
Storoscheff,  of  Moscow,  t  It  may  be  stated  that  the  pressure  of  the 
Scotch  douches  in  these  experiments  did  not  exceed  one  and  a  half  at- 
mospheres (twenty -two  and  a  half  pounds),  which  is  much  less  than  the 
obtainable  pressure  in  the  Hydriatric  Institute  (thirty-five  pounds) ; 
their  duration  was  never  less  than  one  minute,  the  maximum  being 
four  minutes ;  the  temperature  ranged  between  113°  and  59°  F. 

"  The  experiments  were  made  on  two  soldiers  and  lasted  twenty-seven 
days,  the  mode  of  life  being  monotonous  and  nutriment  consisting  of 
bread,  milk,  bouillon,  and  roast  beef.  The  consumption  of  nitrogen  was 
increased  (25  and  23.8  per  cent) ;  assimilation  of  nitrogenous  elements 
was  increased  (3  per  cent) ;  body  weight  increased ;  mouth  temper- 
ature diminished  1-1.3°  C.,  and  remained  somewhat  lower  (0.2°) 
after  an  hour.  The  pulse  diminished  10-16  beats,  and  continued  6-10 
beats  slower  for  half  an  hour.  The  respiration  was  slowed  4—8  inspi- 

*  Croonian  Lectures  on  "The  Blood  and  Circulation,"  London  Lancet,  June 
27th,  1896. 

f  Blatter  f  iir  klinische  Hydrotherapie,  November,  1893. 


260        THE   PRINCIPLES   AND   PRACTICE   OF    HYDRO-THERAPY. 

rations,  continuing  2-6  slower  for  half  an  hour.  Sense  of  location  was 
diminished,  i.e.,  the  arms  of  the  sesthesiometer  had  to  be  extended  8-11 
mm.  The  electrical  excitability  became  more  pronounced,  as  proved 
by  the  diminution  of  the  number  of  milliamperes  of  the  constant  cur- 
rent required  for  the  production  of  muscular  contractions;  fifteen 
minutes  later  1.09  milliamperes  less  were  required  for  exciting  the 
accessory  nerve  of  Willis  and  the  facial  nerve.  This  effect  lasted 
sometimes  for  half  an  hour.  In  order  to  obtain  the  minimum  contrac- 
tions of  a  muscle  from  the  faradic  stream  fifteen  minutes  after  a  Scotch 
douche,  a  weaker  stream  sufficed.  These  effects  may  have  been  due  to 
a  diminution  of  resistance  in  the  skin  after  being  treated  by  the  Scotch 
douche.  Signs  of  pressure  produced  with  a  coin  (modified  procedure  of 
Fleming)  were  observed  in  thirty  instances.  The  evidences  of  pressure 
generally  disappeared  much  more  rapidly  after  the  douche  than  before 
it,  probably  due  to  increased  resistance  of  the  compressed  skin.  The 
sense  of  touch  was  tested  with  Sieveking'  s  sesthesiometer,  and  the  tem- 
perature sense  with  Nothnagel's  thermo-aesthesiometer,  both  showing 
decided  diminution  after  the  douche,  the  latter  falling  1.8°  C.  and  the 
former  thirteen  millimetres,  due  to  reduction  of  nerve  excitability. " 

Heggelin*  summarizes  his  observations  on  the  douche  as  follows: 

"  1.  Every  cold  or  hot  douche  calls  forth  an  increase  of  blood  pres- 
sure. 

"  2.  This  depends  (a)  upon  the  individuality  of  the  animal ;  (b)  the 
force  of  the  douche,  the  stronger  increasing  it  more ;  and  (c)  its  dura- 
tion, which  also  increases  it ;  (d)  the  first  douche  is  the  most  effective. 

"  3.  The  duration  of  increased  blood  pressure  depends  (a)  upon  the 
individuality  of  the  animal ;  (b)  upon  the  temperature ;  lasting  longer 
after  cold  douches. 

"  4.  The  after-effect  of  the  douche,  especially  after  frequent  repeti- 
tion, is  a  sinking  of  blood  pressure  (minimum,  2  mm.  Hg. ;  maximum, 
70  mm.  Hg.),  which  continues  for  some  time. 

"5.  Occasionally  apparently  spontaneous  rises  of  blood  pressure 
occur  after  the  douche. 

"  6.  Even  after  section  of  the  vagus  the  blood  pressure  is  increased 
by  douches." 

Upon  the  heart  similar  effects  are  produced.  Each  douche  im- 
proved cardiac  capacity,  which  depends  upon  the  age  of  the  animal  (the 
younger  the  more  favorably  influenced),  and  upon  the  number  of 
douches,  the  first  acting  better  than  the  subsequent.  The  duration  of 
the  favorable  influence  upon  the  heart  depends  upon  the  same  factors. 

Heggelin  makes  the  following  practical  deductions  from  his  experi- 
*  Inaugural  Dissertation,  1894. 


THE   DOUCHE.  261 

ments  on  animals.  "  Brief  douches  (ten  to  fifteen  seconds)  generally 
act  better  than  those  of  longer  duration;  the  general  conditions  should 
always  be  carefully  observed  when  douches  are  used  for  a  long  time. 
The  action  of  the  heart  certainly  is  improved  by  the  douche;  not  only 
its  power  but  the  utility  of  its  contractions  is  enhanced.  In  diseases 
in  which  a  rise  of  blood  pressure  is  to  be  avoided,  the  douche  should 
not  be  used  (aneurism,  atheromatous  conditions,  etc.).  It  should  be 
carefully  applied  in  aged  people  suffering  from  respiratory  troubles, 
because  the  rise  of  blood  pressure  in  the  left  auricle,  which  sometimes  is 
pronounced,  may  easily  induce  stasis  with  dyspnoea,  hemorrhages,  etc." 

Ottfried  Milller  *  reports  as  the  result  of  2,000  experiments  on  the 
human  being,  that  a  strong  douche  increases  blood  pressure  even  if  it 
is  of  neutral  temperature,  but  that  by  increasing  or  diminishing  the 
temperature  the  blood  pressure  may  be  increased  or  diminished,  with 
this  difference,  viz.,  that  hot  douches  accelerated  the  pulse,  while  cold 
douches  diminished  its  rate.  The  temperature  of  the  douches  varied 
from  28°  to  42°  C.  My  observations  are  in  accordance  with  those  of 
Mliller,  with  the  exception  that  douches  of  28°  C.  (82.4°F)  which  Mtlller 
refers  to  as  the  highest  temperature  he  used,  produced  no  increase  of 
pulse  rate ;  but  temperatures  above  105°  F.  did  increase  it  if  prolonged 
beyond  one  minute.  The  jet  douche  produces  greater  blood  pressure 
than  the  fan  douche,  by  reason  of  the  milder  mechanical  effect. 

Uhlichf  reports  from  Brieger's  Hydrotherapeutic  Institute  of  the 
Berlin  University  that  his  observations  with  the  ergograph  before  and 
after  hydriatric  procedures  show : 

1.  That  the  very  hot,  short  douche  followed  by  a  brief  cold  douche 
affords   the  most  invigorating  effect,   as  has  been  demonstrated  by 
Kellogg. 

2.  The  Scotch  douche,  cold  jet  douche,  half  bath,  cold  rub,  and 
brief  dips  in  hot  water,  followed  by  a  cold  procedure,  are  invigorat- 
ing in  proportion  to  the  mechanical  irritation  (friction  or  hydrostatic 
pressure). 

3.  Indifferent  (neutral)  temperatures  are  without  effect. 

4.  Protracted  warm  baths  enfeeble  the  muscles. 

.  5.  The  removal  of  the  fatigue  which  ensued  after  douches  in  healthy 
persons,  and  rarely  failed  in  the  feeble  and  sick,  was  more  pro- 
nounced than  the  invigorating  effect  upon  a  muscle  that  was  not 
fatigued. 

Effect  of  the  Douche  on  Respiration  and  Tissue  Change. — Rubner  J 
found  that  a  douche  of  16°  (K.  ?)  (68°  F.),  given  before  a  meal,  pro- 

*  Congress  f.  innere  Medizin,  1902,  pp.  408-410. 

f  Zeitschrift  f iir  experimentelle  Pathologic  und  Therapie,  1906. 

\  Loc.  cit. 


°f 


262       THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

duced  an  increase  of  respiration  volume  amounting  to  54.5  per  cent, 
an  increase  of  COa  excretion  amounting  to  149.4  per  cent,  and  of  oxy- 
gen consumption  as  high  as  110  per  cent.  The  respiratory  quotient 
rose  from  0.87  to  1.02. 

Heat  Production. — Differing  from  the  effect  of  short  cold  baths  is 
the  heat  production  after  cold  douches,  which,  according  to  Janowsky, 
is  decidedly  increased,  showing  clearly  the  active  influence  of  the 
douche  upon  tissue  change.  The  total  effect  of  the  douche  is  more 
than  double  that  of  a  short  bath.  The  effect  of  the  hot  douche  upon 
heat  production  and  elimination  has  been  studied  by  Ignatowski.* 


Hot  Douche. 
Before  douche  of  36°  R.  (113°  F.). 
"Weight  79  1  kilos 

2  mins.  after 
Douche. 

78.8  kilos. 

H  hours  later. 

Change. 
Dim 

Heat  elimination  in  J  hour,  19.906  .  .  . 
Heat  production  for  £  hour,  18.595.  .  . 
Rectal  temperature,  slightly  reduced 
(0.05°  C.). 

Cold  Douche. 

Before  douclie  of  13°  R.  (61°  F.)  press. 
45  Ibs.,  dtir.  1J  min. 

Weight,  54.8  kilos  

21.7 
13.9 

Same 

22.546 
12.0 

54  8  kilos 

Inc. 
Dim. 

Same 

Heat  elimination  in  ^  hour,  20.85.  . 

19.66 

18  6 

Dim 

Heat  production  for  £  hour,  16.87.  .  .  . 

19.16 

13.14 

Dim. 

The  rectal  temperature  was  slightly  reduced  (.55°  C.)  and  rose  later 
and  higher  than  after  short  cold  baths.  Active  movements  during  the 
douche,  and  the  enhanced  refreshment  following  it,  increase  reaction 
and  therefore  vaporization  of  moisture,  as  well  as  heat  production  for 
about  forty-five  minutes,  which  is  a  much  more  protracted  effect  than 
that  following  short  baths. 

These  laboratory  and  clinical  observations  on  the  rationale  of  its 
action  clearly  demonstrate  how  important  it  is  to  avoid  a  careless  pre- 
scription of  the  douche — the  nature  of  each  special  case,  the  condi- 
tions of  each  individual,  his  reaction  to  the  douche,  must  be  carefully 
considered.  "We  must  individualize  and  control." 

Therapeutic  Indications  of  the  Douche. — In  all  those  diseased  con- 
ditions in  which  the  loss  of  muscular  vigor  is  the  result  of  feeble  diges- 
tion, of  depreciated  nerve  tone,  or  even  of  organic  disease,  the  douche 
in  its  numerous  modifications  offers  a  method  of  restoring  vigor  which 
is  often  surprising  by  reason  of  the  rapidity  and  completeness  of  the 
result.  There  is  no  hydriatric  procedure  that  can  approach  it  in  im- 
proving the  general  circulation,  as  well  as  the  tonicity  of  the  smaller 

*  Loc.  cit. 


THE   DOUCHE.  263 

vessels  and  of  the  tissues.  It  deepens  the  respiration,  and  thus  gives 
rise  to  the  exchange  of  gases  which  enhance  tissue  change.  As 
Pospischl  says:  "The  mechanical  massage  produced  by  a  good  fan 
douche  sets  the  diseased  structures  into  a  vibration  which  cannot  be 
overestimated  and  is  not  to  be  approached  by  ordinary  manual  massage. " 

It  may  be  used  in  feeble  subjects  who  are  able  to  stand,  because  it 
does  not  abstract  much  heat;  and  may  be  preceded  by  the  dry  pack 
or  brief  hot-air  bath,  which  accumulates  upon  the  surface  all  the  heat 
to  be  abstracted  and  thus  forestalls  any  actual  heat  loss.  In  hypertro- 
phies of  the  liver  and  spleen,  in  chronic  rheumatism,  malarial  fever  with 
and  without  cachexia,  in  many  psychoses,  the  superiority  of  the  douche 
over  all  other  procedures  has  been  observed  by  the  writer.  Its  applica- 
tion in  some  of  these  affections  will  be  referred  to  at  greater  length. 

In  enuresis  of  children,  I  have  observed  great  benefit  from  the  cir- 
cular douche  in  the  New  York  Juvenile  Aslyum.  Dr.  Prendergrast 
reports*  eighty  cases  of  enuresis  which  he  has  observed  in  an  orphan 
asylum.  "  The  usual  treatment  had  failed,  when  one  of  the  sisters  sug- 
gested cold  water.  The  child  was  made  to  stand  in  an  empty  tub, 
while  cold  water  was  allowed  to  run  for  several  minutes  over  his  shoul- 
ders and  back  from  an  ordinary  watering-can.  The  child  was  dried, 
rubbed,  and  put  to  bed.  Sponging  with  cold  water  had  no  effect. 

"  Eighty  per  cent  of  the  cases  were  completely  cured,  while  others 
were  improved,  without  any  other  special  attention  to  diet,  etc.  The 
boys  were  from  six  to  twelve  years  old ;  some  of  them  also  suffered  from 
enuresis  during  the  day.  This  large  experience  and  simple  treatment 
are  worthy  of  imitation,  even  if  we  cannot  construct  a  plausible  theory 
for  the  favorable  effect  of  the  latter. " 

In  ancemia  and  chlorosis;  in  neurasthenia  of  the  depressed  type; 
with  introspeetion  and  melancholic  ideas ;  in  gastric  and  other  troubles, 
requiring  a  heightening  of  muscular  energy ;  in  all  those  conditions 
in  which  an  elevation  of  nerve  tone  is  demanded,  we  have  in  the  douche 
a  most  powerful  weapon  for  good,  and  I  may  say  also  for  evil.  Like  a 
two-edged  sword,  it  may  inflict  damage  when  carelessly  used.  It 
should  never  be  administered  without  the  prescription  of  a  physician, 
who  should  designate  the  duration,  temperature,  and  amount  of  pres- 
sure of  a  douche,  whose  effect  is  governed  not  only  by  these,  which 
may  be  mathematically  measured,  but  by  the  constitutional  peculiarities 
of  the  patient  and  by  modifications  impressed  by  the  existing  disease. 

Cardiac  Affections. — The  Parisian  clinician  Huchard  expresses  him- 
self as  follows  before  the  Paris  Academyof  Medicine :  "  In  heart  diseases 
and  in  various  other  pathological  conditions,  heart  weakness  is  very  often 
dependent,  not  only  upon  the  heart  itself  and  its  innervation,  but  also 
*New  York  MedicalJourual,  June  llth,  1896. 


264        THE   PRINCIPLES  AND   PRACTICE   OF   HYDEOTHERAPY. 

upon  peripheral  resistance,  and  when  this  is  overcome  the  general 
disturbance  ceases. "  He  refers  to  the  "  peripheral  heart "  and  its  adapt- 
ability for  combating  symptoms  of  arterio-sclerosis,  and  claims  that  it 
is  especially  in  these  conditions  that  rational  hydrotherapy  renders 
such  efficient  service.  The  neutral  rain  douche  is  particularly  appli- 
cable in  these  conditions.  The  duration  is  one  to  two  minutes,  the 
temperature  being  gradually  lowered  till  the  patient  feels  a  pleasant 
sensation  of  cold,  then  increased  again.  This  form  of  douche  prevents 
a  strong  reaction  and  exerts  a  very  favorable  influence  on  the  periph- 
eral circulation.  By  this  means  the  heart  is  greatly  relieved  and  thus 
strengthened. 

"The  neutral  douche  furnishes  the  greatest  security  against  high 
tension  of  the  vessels.  The  gentle  application  of  the  water  should  not 
excite  a  sensation  either  of  heat  or  cold;  it  should  be  adapted  to  the 
individual,  and,  to  accomplish  this,  may  be  varied  from  33°  to  37°  C. 
(91.4°-98.6°  F.).  The  douche  should  be  administered  with  very  slight 
pressure,  to  avoid  irritation,  and  is  to  be  directed  especially  to  each 
side  of  the  spinal  column.  The  duration  varies  according  to  the  case, 
from  three  to  eight  minutes.  This  sedative  application  quiets  the 
nervous  system  and  circulation,  and  for  this  reason  is  indicated  in  all 
-conditions  which  are  caused  by  an  increase  of  arterial  tension." 

Increase  of  Arterial  Tension. — "  The  short  cold  douche  improves 
arterial  tension  and  restores  the  circulation  to  a  normal  condition. 
Applications  of  cold  water  have  a  widely  differing  influence,  according 
to  their  intensity  and  the  sensitiveness  of  the  patient.  These  impres- 
sions act  reflexly  upon  the  brain  and  spinal  cord,  thus  effecting  a  con- 
nection with  all  the  tissues  and  organs  of  the  body. 

"  By  its  reaction,  as  well  as  by  its  direct  effect,  a  short  cold  douche 
produces  an  increase  of  nervous  activity,  of  muscular  contraction,  and 
an  acceleration  of  the  circulation.  This  transient  increase  of  the  most 
important  functions  of  the  organism  has  something  to  do  with  the  in- 
crease of  arterial  tension.  Its  extent  is  always  in  proportion  to  the 
intensity,  duration,  and  reaction  of  the  cold  application.  The  short 
cold  douche  is  for  this  reason  a  sure  means  of  increasing  pressure." 

This  brief  review  of  the  mechanism,  rationale,  and  therapeutic  indi- 
cations of  the  douche,  offers  the  principles  for  its  application  which 
would  enable  the  intelligent  institution  physician  to  adapt  it  to  the  vari- 
ous diseases  in  which  an  improvement  of  assimilation  and  haematosis, 
elevation  of  depreciated  nerve  tone,  equalization  of  perverted  nerve 
force,  absorption  of  pathological  products,  or  increase  of  tissue  change 
is  demanded. 

An  imperfect  mode  of  douching  may  appropriately  be  referred  to  at 
this  point.  With  the  fact  lost  sight  of  that  the  chief  element  contrib- 
uting to  the  value  of  the  douche  is  the  pressure  with  which  we  are 


THE   DOUCHE.  265 

enabled  to  deliver  it,  the  procedure  is  not  infrequently  prescribed  in 
domestic  practice.  The  patient  or  nurse  is  directed  to  attach  a 
"  spriukler"  to  the  bathroom  or  washstand  faucet,  and  allow  the  spray 
to  play  upon  the  spine,  back,  or  entire  body.  The  writer's  observation 
that  such  a  procedure  may  be  borne  only  by  the  most  robust,  and  that 
therefore  it  is  entirely  unadapted  to  patients  of  feeble  circulation  or 
depreciated  nerve  tone,  is  doubtless  shared  by  many.  His  first  ex- 
perience with  a  warm  bath  followed  by  such  a  cold  spray  was  obtained 
in  midsummer,  the  cold  water  being  about  70°.  Ten  minutes  after  the 
spraying,  he  found  himself  unable  to  turn  his  head  or  move  his  right 
arm  without  severe  pain.  Then  a  brief  but  sharp  attack  of  myalgia 
was  inaugurated.  Since  that  time  patients  have  often  related  a  similar 
experience,  or  stories  of  chilling,  which  led  them  to  conclude  that  they 
"could  not  bear  cold  water."  The  reason  is  plain.  In  the  upper 
stories  of  most  New  York,  and  probably  also  in  other  city  houses,  the 
water  pressure  is  not  over  ten  pounds ;  in  the  third  story  it  may  be 
only  three  or  four  pounds.  The  stream  issuing  through  a  sprinkler 
would  therefore  be  a  "drizzle;"  the  mechanical  effect  being  slight, 
reaction  is  not  developed,  the  result  being  chilliness  and  depression 
rather  than  warmth  and  stimulation.  Except  in  large  apartment 
houses  receiving  the  water  supply  from  tanks  upon  the  roof,  private 
city  residences  do  not  furnish  sufficient  pressure  for  a  good  douche. 
Moreover,  a  douche  cannot  fulfil  its  purpose  with  any  degree  of  satis- 
factory result  xmless  a  thermometer  be  so  arranged  as  to  facilitate  the 
proper  admixture  of  warm  and  cold  water,  and  to  indicate  the  tem- 
perature after  admixture.  Properly  to  adapt  the  douche  to  each  case 
and  the  varying  phases  of  the  case,  a  pressure  gauge  is  also  necessary. 
Such  an  arrangement  being  rarely  found  in  private  houses,  the  douche 
should  be  administered  in  institutions  only.  In  this  respect,  therefore, 
this  procedure  differs  from  others,  as  ablutions,  packs,  and  the  various 
baths,  all  of  which  are  more  conveniently  administered  at  the  patient's 
home,  if  a  properly  instructed  attendant  can  be  obtained. 

Having  observed  that  many  patients  have  been  discouraged  by  the 
improper  use  of  the  douche  as  well  as  of  other  procedures,  and  others 
have  been  led  to  regard  themselves  as  possessing  an  idiosyncrasy 
against  "cold  water,"  the  author  deems  it  important  to  reiterate  his 
warning  against  imperfect  hydrotherapy,  whenever  opportunity  offers, 
in  a  work  which  aims  to  become  a  practical  guide  to  the  general  practi- 
tioner in  the  judicious  therapeutic  use  of  water. 

The  Douche  in  Hydriatric  Clinics. — For  the  demonstration  of  the 
physiological  and  therapeutic  effects  of  hydrotherapy  the  douche  is 
well  adapted,  by  reason  of  its  capacity  for  rapid  and  perfect  applica- 
tion of  temperature,  duration,  and  pressure  which  may  thus  be  shown 
to  students  upon  whose  minds  valuable  and  enduring  lessons  may  thus 


266        THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

be  impressed.  In  the  hydrotherapeutic  department  of  Columbia  Uni- 
versity (College  of  Physicians  and  Surgeons),  which  is  part  of  the 
Vanderbilt  Clinic,  the  douche  apparatus  devised  by  the  author,  and 
constructed  under  his  direction  by  the  Hydrotherapeutic  Apparatus  Co. 
of  this  city,  is  in  successful  and  satisfactory  operation.  The  object  be- 
ing chiefly  for  instruction,  only  males  are  treated,  for  obvious  reasons. 

For  polyclinical  work  the  douche  presents  the  great  advantage  of 
rapidity  of  treatment  and  establishment  of  a  reaction  which  does  not 
compel  the  patient  to  remain  indoors  and  thus  crowd  the  clinic.  As 
an  illustration  may  be  cited  the  Hydriatric  Clinic  at  259  West  Sixty- 
ninth  Street,  which  I  established  twelve  years  ago.  During  the  year 
ending  June  30th,  1904,  27,355  douches  were  administered,  always 
preceded  by  hot-air  baths  to  enhance  reactive  capacity.  This  is  an 
average  of  75  for  each  day;  the  institution  is  open  four  hours  on  Sun- 
day morning.  This  rapid  disposition  of  patients  without  neglect  or 
superficial  attention,  is  accomplished  by  rotation  which  is  facilitated 
by  drying-rooms  in  which  two  patients  may  dry  themselves  while  a 
third  is  receiving  the  douche.  The  doucheur  or  doucheuse  only  assists 
feeble  patients,  whose  number  is  insignificant.  A  masseur  assists  in 
placing  the  patients  into  the  hot  boxes,  wrapping  their  heads  in  cold 
turbans,  watching  extent  of  perspiration,  administering  small  cold 
drinks,  and  removing  them  from  the  boxes,  and  otherwise  assists  with 
the  distribution  of  towels,  etc.  Despite  this  large  number  there  are 
other  hydriatric  procedures  administered.  The  large  clientele  of  this 
clinic  is  furnished  by  the  outdoor  departments  of  the  New  York, 
Roosevelt,  Presbyterian,  Postgraduate,  Mt.  Sinai,  Bellevue,  and  Beth 
Israel  hospitals,  and  by  the  dispensaries  of  the  Cornell  and  New  York 
and  Bellevue  medical  schools,  German,  St.  Bartholomew's,  and  other 
dispensaries.  As  other  procedures  require  more  time  than  can  be  al- 
lotted, about  96  per  cent  of  the  cases  receive  douches,  which  are  sub- 
stituted for  them  because  the  duration,  temperature,  and  mechanical 
effect  can  be  modified  to  suit  each  case;  the  exception  being  wet  packs 
and  continuous  or  other  hoth  baths  in  rheumatism  and  other  diseases 
of  faulty  tissue  change. 

The  author  would  recommend  the  adoption  of  the  arrangement 
illustrated  and  described  under  the  caption  of  "  Hydrotherapeutic  Ap- 
paratus "  for  purpose  of  institution  work  and  for  clinical  work.  Thou- 
sands of  cases  have  demonstrated  its  value.  The  proper  construction 
of  the  apparatus  is  an  important  consideration.  If  the  material  or 
workmanship  is  defective  it  may  not  be  visible  until  the  apparatus 
ceases  to  be  useful.  The  cost  of  repairs  is  the  least  disadvantage;  the 
loss  of  treatment  for  patients  requiring  it  is  far  more  disturbing,  es- 
pecially if  the  apparatus,  or  part  of  it,  must  be  sent  away  for  repairs. 


CHAPTER   X. 


THE  HIP  BATH. 

THIS  method  of  applying  water  to  the  lower  part  of  the  trunk  is 
sometimes  termed  a  sitz  bath,  from  the  German  sitzen,  to  sit,  because 
the  patient  sits  in  a  tub  of  water  which  covers  the  pelvic  portion  of  the 
body,  usually  as  far  as  the  umbilicus. 

The  hip  bath  is  prepared  as  follows :  An  oil  cloth,  covered  by  one 
or  more  blankets,  is  spread  upon  the  floor ;  a  tub,  shaped  as  indicated  in 

Fig.  55,  is  so  placed  that  its  pos- 
terior border  stands  upon  a  line 
with  the  posterior  edge  of  the 
outstretched  blankets;  water  of 
the  prescribed  temperature  having 
been  prepared  in  pails,  the  tub  is 
filled  to  one-half  its  capacity.  The 
patient,  having  his  head  covered 
with  a  damp  turban,  is  now  seated 
in  the  tub,  with  his  lower  ex- 
tremities passing  over  the  anterior 
edge  of  the  tub.  To  prevent  pres- 
sure, the  popliteal  surface  of  the 
knee  should  be  made  to  clear  the 
edge,  and  be  placed  at  a  sufficient 
angle  with  the  thigh  to  be  com- 
fortable. If  the  patient  be  of 
short  stature,  a  small  stool  or  other 
support  for  the  feet  may  be  made 
to  raise  the  lower  extremities  suffi- 
ciently off  the  floor  to  permit  the 
knees  to  clear  the  edge  of  the 
tub.  The  upper  blanket  is  now 
snugly  wrapped  around  the  feet 
and  legs,  because  the  latter,  being 
FIG.  55.— Hip  Bath.  outside  of  the  tub  and  not  sub- 

jected  to  friction,    are   liable    to 

become  cold.     The  feet  may  be  held  within  a  small  tub  of  water  at 
105°  to  110°,  as  a  substitute  for  the  blanket. 


268        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

If  the  patient  is  very  sensitive,  or  water  of  a  very  high  or  a  very  low 
temperature  is  to  be  used,  it  is  advisable  to  allow  the  water  in  which 
the  patient  is  seated  to  be  of  five  or  ten  degrees  lower  or  higher  tem- 
perature in  the  beginning,  in  order  not  to  shock  or  disturb  him ;  but 
this  is  scarcely  necessary.  A  sufficient  quantity  of  water  of  the 
proper  temperature  is  now  rapidly  added  in  such  manner  that  it 
flows  into  the  tub  without  touching  the  patient,  while  he  is  made  to 
use.  active  friction  of  the  lateral  and  anterior  submerged  parts  of  the 
body.  The  entire  preparation  of  the  bath  should  be  accomplished 
quickly,  to  prevent  discomfort.  Unless  otherwise  ordered  by  the 
physician,  the  attendant  should  apply  friction  during  the  entire  bath, 
passing  his  hands  with  or  without  a  washcloth  or  a  bath  glove  over 
the  entire  lumbar  and  lateral  regions,  while  the  patient  applies  friction 
over  his  abdomen  and  thighs. 

A  badly  executed  hip  bath  will  chill  the  patient  or  render  him 
otherwise  uncomfortable.  The  nurse  should  therefore  carefully  attend 
to  an  exact  execution  of  the  above  directions,  especially  with  regard  to 
the  comfortable  posture  of  the  patient  and  active  friction. 

Rationale. — The  exact  and  interesting  experiments  made  by  Drs. 
Schweinburg  and  Pollak,  under  the  guidance  and  at  the  suggestion  of 
Professor  Winternitz,  afford  a  rational  basis  for  deducing  the  thera- 
peutic effect  of  hip  baths.  The  individual  was  placed  into  an  empty 
tub,  in  order  to  avoid  errors  arising  from  change  of  pressure,  and 
covered  with  blankets.  Dudgeon's  sphygmograph  was  secured  to  the 
radial  artery  in  a  comfortable  position  of  the  arm ;  the  carotid  pulse 
was  counted,  and  the  blood  pressure  of  the  temporal  artery  was  re- 
corded. Now  water  at  the  desired  temperature  was  poured  into  the 
tub.  Thus  the  observations  were  made  before,  during,  and  after  the 
hip  bath.  The  results  were  as  follows :  The  hot  hip  bath  (104°-113° 
F.)  produced  almost  without  exception  slight  increase  of  the  pulse  rate 
and  occasionally  considerable  reduction  of  blood  pressure,  while  the  cold 
bath  (50°-54.5°)  produced  a  slight  diminution  of  the  pulse  rate  and 
occasionally  considerable  elevation  of  blood  pressure. 

According  to  Winternitz,  the  sitz  bath  is  a  potent  factor  in  in- 
fluencing the  circulation  of  that  immense  vascular  area  comprised  in 
the  intra-abdominal  vessels.  This  system  of  vessels  may  be  compared 
to  a  reservoir  of  flexible  dimensions,  whose  mission  it  is  to  receive  tem- 
porarily all  blood  from  other  parts,  to  which  it  is  again  returned  when 
needed.  The  capacity  for  changing  their  calibre  and  area  renders  the 
intra-abdominal  vessels  a  kind  of  safety  valve  for  regulating  the  pres- 
sure relations  in  the  entire  vascular  system,  as  has  been  shown. 

Any  procedure,  therefore,  which  may  powerfully  influence  these 
vessels  must  be  potent  for  good  as  well  as  for  evil.  It  has  already  been 


THE   HIP   BATH.  269 

mentioned  in  the  first  part  of  this  book  (page  46),  that  the  plethysmo- 
graph  distinctly  registers  an  increase  of  volume  in  the  upper  extremi- 
ties when  an  individual  is  placed  in  a  cold  sitz  bath.  There  is  a  rush 
of  blood  to  the  head,  manifested  by  the  usual  symptoms.  Otherwise 
the  effect  is  the  same  upon  the  respiration,  circulation,  tension,  etc., 
as  from  the  impact  of  cold  water  upon  any  other  part  of  the  body. 
There  is  no  other  method  by  which  blood  may  be  driven  to  the  upper 
portion  of  the  body.  All  the  effects  of  this  bath  may  be  traced  to  a 
reflex  excitation  of  the  sympathetic  nerve. 

Hip  baths  from  50°  to  70°  F.,  of  from  ten  to  twenty  minutes'  dura- 
tion, excite  the  vasomotor  nerves  of  the  abdominal  organs,  contracting 
these  vessels,  diminishing  their  calibre  and  contents,  and,  as  a  result, 
the  intestinal  secretions  and  peristaltic  movements. 

The  therapeutic  indications  based  upon  this  rationale  of  the  action 
of  the  hip  bath  are  readily  deduced.  In  all  conditions  of  hyperaemia 
of  the  intra-abdominal  organs,  in  diarrhoea  and  dysentery,  hip  baths 
may  be  of  great  service.  Brief  dipping  of  the  lower  abdomen  into  cold 
water,  on  the  contrary,  produces  hyperaemia  of  the  organs,  increasing 
the  tone  of  the  intestines,  enhancing  their  functional  activity,  while 
prolonged  hot  or  cold  hip  baths  (of  one  or  two  hours'  duration)  pro- 
duce a  relaxation  of  the  intra-abdominal  vessels  and  a  corresponding 
effect  upon  the  blood  distribution  in  neighboring  parts.  Winternitz 
insists,  and  I  am  able  to  corroborate  this  clinical  observation,  that 
there  is  no  remedy  which  is  so  efficacious  in  the  most  obstinate  diarrhoeas 
as  a  cold  hip  bath  which  has  been  preceded  by  an  energetic  wet  sheet 
rubbing.  The  latter  increases  the  cutaneous  vascular  area,  while  the 
hip  bath  of  50°-66°  F.  excites  the  sympathetic,  contracts  the  intestinal 
vessels,  and  diminishes  peristaltic  action,  if  prolonged. 

In  diseases  of  the  urinary  and  sexual  organs,  brief  cold  hip  baths 
are  useful,  when  there  is  a  sluggish  circulation  or  stasis  from  chronic 
congestion  or  inflammation,  while  in  active  pathological  conditions  they 
are  contraindicated.  Hence,  in  impotence,  spermatorrhoea,  subacute 
and  chronic  ovaritis,  in  atonic  conditions  of  the  uterus  and  its  liga- 
ments, in  amenorrhcea  and  passive  menorrhagia,  these  baths  are  indi- 
cated, as  also  in  passive  congestions  of  the  brain,  lungs,  and  liver,  in 
gastric  and  intestinal  ailments,  constipation,  etc. 

The  most  striking  results  have  been  observed  by  the  author  in  those 
cases  of  profuse  menstruation  which  drag  on  from  month  to  month, 
leaving  the  patient  exhausted  and  anaemic  and  thus  establish  a  vicious 
circle  which  maintains  the  drain.  When  curetting  has  failed  or  is 
not  indicated,  the  flow  being  maintained  by  a  feeble  local  and  general 
circulation,  hip  baths  of  five  or  eight  minutes,  in  water  at  85°  F., 


270        THE   PRINCIPLES   AND    PRACTICE   OF   HYDROTHERAPY. 

with  constant  friction,  followed  by  affusions  or  preferably  by  the  cir- 
cular bath  and  then  douches  at  the  same  or  a  lower  temperature,  far 
excel  all  medicinal  agents.  It  is  the  author's  custom  in  such  cases  to 
order  the  hip  baths  at  85°  F.  for  eight  to  ten. minutes,  terminated  by 
an  affusion  with  water  at  70°  or  less  for  general  tonic  effect  on  the  fifth 
day  of  the  menstruation,  when  the  latter  arrives  at  a  distinct  period,  and 
to  continue  it  daily  until  the  flow  has  ceased.  If  no  distinct  period  ex- 
ists, the  hip  bath  should  be  ordered  after  the  flow  has  become  profuse, 
and  it  should  be  continued  until  the  flow  ceases.  Not  only  will  the 
drain  be  thus  checked,  but  the  tonic  effect  of  such  a  bath  will  counter- 
act the  depreciated  systemic  condition  and  restore  the  patient's  health 
and  spirits.  Most  women  object  strenuously  to  the  cold  hip  bath  in 
menstrual  disorders.  It  is  therefore  wise  to  forestall  their  fears  by 
reassuring  them  of  the  necessity  and  great  value  of  brief  hip  baths  in 
these  conditions. 

Contraindications. — Cold  hip  baths  are  especially  contraindicated 
in  all  irritable  conditions  of  the  uro-genital  organs  with  frequent  emis- 
sions. It  is  a  serious  and  common  error  to  suppose  that  the  ordinary 
cold  hip  bath  is  calming  or  depressing  to  the  pelvic  organs.  It  is  cer- 
tain that  a  very  brief  dip  of  the  pelvis  into  cold  water  increases  the 
energy  and  pressure  of  the  portal  circulation.  The  prolonged  cool  hip 
bath,  on  the  contrary,  reduces  temperature  for  the  time,  and  tends  to 
prevent  reaction  and  consequent  stimulation.  Such  a  hip  bath  may  aid 
in  relieving  inflammatory  conditions,  if  it  be  of  ten  or  twenty  minutes' 
duration  and  of  50°-90°  F.  In  cystitis,  urethritis,  uterine  hemorrhage, 
and  prostatitis,  in  diarrhoea,  dysenteries,  these  prolonged  hip  baths 
are  exceedingly  useful.  When  a  decidedly  calming  effect  is  desired 
the  warm  hip  bath  of  one  or  two  hours'  duration,  95°-100°  F.,  is  a 
long-established  remedy  for  vesical  tenesmus,  menstrual  pains,  etc. 

But  the  most  valuable  pelvic  antiphlogistic,  hip  bath  is  produced 
with  water  at  70°-80°  F.,  with  friction.  The  author  has  found  a 
gradually  cooled  hip  bath,  beginning  at  90°  and  gradually  adding  ice- 
water  from  a  pitcher  so  as  not  to  touch  the  body  until  80°  are  reached,, 
useful  in  chronic  utero-vaginal  trouble,  when  not  connected  with  pus 
formations. 

An  excellent  practical  article  by  Misiewitz*  summarizes  the  effect 
of  hip  baths  as  follows :  "  Brief  cold  hip  baths,  whose  effect  is  excitant 
and  productive  of  intense  reflex  hyperaemia,  are  indicated  in  paralysis 
of  the  muscular  fibres  of  the  bladder  and  intestines  ;  in  prolapsus  ani, 
spermatorrhoea,  prostatorrhcea,  impotence  of  men  arising  from  muscular 

*  "  Klinische  Untersuchungen  fiber  die  Wirkung  der  Sitzbader  bei  Krank- 
heiten  des  Urogenital-Systems  und  anderer  Organe  der  Bauchhohle,"  Wiener 
klinische  Wochenschrift,  1895,  No.  12. 


THE   HIP   BATH.  271 

debility  and  cutaneous  anaesthesia;  in  weakness  of  the  uterine  liga- 
ments; prolapsus  uteri;  leucorrhoea  due  to  chlorosis,  and  menostasis; 
some  forms  of  passive  hemorrhages  ;  liver  hypercemia  ;  muscular  atony 
of  gastric  and  intestinal  coats,  manifested  by  constipation,  flatulence, 
etc. 

"  Cold  hip  baths  are  contraindicated  in  conditions  of  excessive  irri- 
tability, active  hypersemia  or  inflammation  of  the  pelvic  organs;  in 
increased  sexual  irritability,  pollution  •,  in  vesical  and  rectal  tenesmus ; 
and  in  active  menorrhagia. 

"  The  prolonged  cold  hip  bath  possesses  entirely  different  properties ; 
it  reduces  the  temperature  of  the  abdominal  canal  for  a  considerable 
time,  quiets  the  centres  controlling  the  abdominal  organs,  diminishes 
tissue  change,  and  does  not  so  much  cause  blood  to  accumulate  as  it 
enhances  the  tone  of  the  arteries ;  it  facilitates  venous  flow  and  regu- 
lates the  normal  circulation.  It  is  therefore  indicated  in  hemorrhages 
from  the  urethra,  bladder,  intestines,  and  uterus;  in  infectious  and 
chronic  catarrh  of  the  uterus ;  in  hemorrhoids,  perimetritis,  peri-or- 
chitis ;  in  gonorrhoea,  prostatitis,  periproctitis ;  in  obstinate  or  bloody 
diarrhoea ;  in  inflammation  of  the  adnexa  and  uterine  ligaments.  The 
prolonged  hip  baths  are  contraindicated  in  the  muscular  contractions, 
observed  in  so-called  uterine  colic  and  in  acute  cystitis  and  intense 
teuesmus.  In  these  cases,  when  tonic  and  spastic  contractions  of  the 
muscles  and  vessels  are  produced  by  excitability  of  the  vasomotors, 
warm  and  steam  baths  are  indicated.  The  latter  are  therefore  most 
effectively  applied  in  tenesmus  of  the  bladder,  urethra,  and  rectum ;  in 
vesical  spasm  produced  by  sexual  or  dietetic  excesses;  in  menstrual  and 
uterine  colics ;  in  contraction  of  the  ureters  and  nephritic  colic ;  and  in 
menostasis  of  the  catamenial  period. 

"  The  effect  of  prolonged  lukewarm  (?)  hip  baths  (72°  F.)  resembles 
the  effect  of  cold  hip  baths  (50°-63°).  They  do  not  produce  exces- 
sive reaction  and  they  reduce  the  abdominal  temperature  for  a  con- 
siderable time.  They  calm  the  terminals  of  the  sensory  nerves  and 
produce  a  slow  and  equable  exercise  in  the  muscular  coats  of  the 
vessels.  Antiphlogistic  action  is,  par  excellence,  the  chief  indication 
for  the  prolonged  lukewarm  hip  bath  in  catarrhs  of  the  urethra  and 
its  adnexa;  in  blennorrhoea,  leucorrhoea,  and  uterine  infarction;  in 
metritis,  cystitis,  proctitis,  hemorrhoids,  oop/ioritis,  colitis,  said,  typhlitis." 

In  constipation  with  anaemia  the  favorable  results  of  brief  hip  baths 
are  occasionally  striking.  Seated  in  a  bath  of  85°,  daily  reduced 
two  degrees  until  60°  is  reached,  the  patient's  abdomen  is  well 
kneaded  and  rubbed.  After  removal  from  the  tub,  an  abdominal 
douche  followed  by  a  general  fan  douche  enhances  the  effect  of  the  hip 
bath  in  the  constipation  of  anaemic  women. 


CHAPTER  XL 

IRRIGATION. 

THE  application  of  water  upon  diseased  surfaces  and  in  cavities 
has  been  aptly  termed  irrigation,  because  the  contact  of  the  water 
with  the  surface  treated  is  brief  and  its  action  chiefly  local. 

The  most  convenient  apparatus  used  for  this  purpose  is  the  ordinary 
fountain  syringe,  which  is  now  made  sufficiently  large  to  hold  the 
quantity  of  water  required  for  any  purpose,  and  which  may  be  replen- 
ished when  necessary.  In  order  to  obtain  the  required  pressure  the 
reservoir  is  suspended  from  a  sufficient  elevation  for  the  purpose  indi- 
cated. In  gynaecological  cases  the  rubber  bulb  syringe  is  preferred  by 
some,  for  reasons  which  will  be  referred  to  later. 

The  technique  of  irrigation  differs  in  accordance  with  the  purpose 
for  which  it  is  applied,  and  will  therefore  be  described  under  the  fol- 
lowing heads : 

1.  Lavage.  2.  Enteroclysis.  3.  Irrigation  of  the  genito-urinary 
canals.  4.  Miscellaneous. 

LAVAGE. 

Lavage  is  a  term  applied  to  the  irrigation  of  the  stomach.  Its 
technique  differs  in  infants  and  adults. 

The  method  of  introduction  in  infants  is  as  follows :  A  No.  8  Nela- 
ton  or  Jacques  catheter,  connected  by  a  piece  of  glass  tubing  to  the 
tube  of  a  fountain  syringe  containing  a  quart  of  water  at  95°  or  100° 
F.,  to  which  a  level  teaspoonful  of  salt  or  bicarbonate  of  sodium  has  been 
added,  is  gently  but  firmly  pushed  through  the  pharynx  or  nose  into  the 
stomach  of  the  child,  while  the  latter  is  held  upright  in  the  nurse's 
arms.  In  young  infants  this  is  not  a  difficult  procedure,  as  they 
will  aid  it  by  sucking  the  tube.  In  older  children  it  is  so  difficult 
sometimes  that  it  is  better  to  avoid  it.  The  procedure  should  not  be 
applied  in  the  presence  of  the  mother  or  of  anxious  friends,  because 
it  occasionally  produces  a  distressed  and  cyanotic  appearance  of  the 
baby's  face,  which,  however,  is  evanescent  and  does  not  denote  harm, 
but  may  interfere  with  the  measure  in  many  instances.  The  catheter 
may  be  introduced  separately,  and  after  being  lodged  in  the  stomach 
may  be  connected  with  the  fountain  syringe  containing  the  boiled 
water.  The  infant  usually  vomits  the  water  received,  but  it  is  better 


IRRIGATION.  273 

to  disconnect  the  catheter  from  the  syringe  and  allow  the  water  con- 
taining products  of  fermentation,  mucus,  and  undigested  curds  to 
escape  through  the  tube.  The  tube  should  be  firmly  held  near  the 
mouth  to  prevent  its  being  washed  out  by  the  gushing  water.  When 
the  procedure  is  finished  the  catheter  should  be  pinched  between  the 
thumb  and  forefinger  of  the  right  hand,  and  withdrawn  rapidly ;  its 
distal  end  is  then  held  over  the  basin  and  the  pinching  hold  relaxed, 
in  order  to  empty  its  contents.  This  precaution  is  necessary  and  im- 
portant, because  it  prevents  the  possible  flow  of  the  fluid  and  solid 
matter  contained  in  the  catheter  from  the  open  end  of  the  latter  into 
the  child's  larynx. 

Therapeutics  of  Infantile  Lavage. — Next  to  proper  regulation  of  diet 
and  hygiene,  the  mechanical  effect  of  gastric  irrigation  is  a  valuable 
remedial  measure  in  obstinate  affections  of  the  gastric  and  intestinal 
tract.  For  the  removal  of  the  ingested  and  multiplying  bacteria  from 
the  gastro-intestinal  canal  of  an  infant  with  summer  diarrhoea,  irriga- 
tion by  a  soft-rubber  tube,  as  introduced  by  Epstein  and  earnestly  ad- 
vocated by  Seibert,  offers  a  valuable  resource  in  obstinate  cases,  even 
after  failure  of  the  most  reliable  remedies. 

Lavage  for  Adults. — The  method  of  applying  lavage  differs  some- 
what when  the  patient  is  an  adult.  The  patient  is  seated  upon  a  chair 
with  another  chair  in  front  of  him.  A  large  towel,  sheet,  or,  better 
still,  a  rubber  apron  is  secured  by  tapes  around  the  neck  and  allowed 
to  cover  the  entire  front  of  the  body,  in  order  to  protect  the  clothing. 
A  long,  soft,  but  firm  rubber  stomach  tube,  with  an  open  end  and  one 
eye  near  the  latter,  and  from  two  to  six  quarts  of  water  being  in  readi- 
ness, a  basin  is  placed  upon  the  chair  in  front  of  the  patient.  Artificial 
teeth,  if  present,  are  removed.  The  patient  is  requested  to  sit  upright 
with  his  head  thrown  back.  The  physician,  standing  on  his  right, 
dips  the  lower  end  of  the  tube  in  warm  water  (oil  is  unnecessary  and 
injures  the  tube  eventually).  Holding  it  like  a  pen  between  the 
thumb  and  forefinger,  he  introduces  the  tube  over  the  tongue,  without 
touching  the  latter,  until  it  strikes  the  back  of  the  pharynx.  The 
patient  is  now  told  to  swallow  and  to  bend  his  head  forward.  In  the 
first  effort  gagging  may  ensue,  but  an  abundant  mucus  is  soon  secreted 
in  the  throat  which  lubricates  the  tube.  The  patient  should  be  reas- 
sured, if  he  complains  of  feeling  choked  or  distressed,  by  informing 
him  before  the  unpleasant  symptom  occurs  that  this  is  the  usual  effect, 
and  that  if  he  will  keep  his  mouth  well  open  he  cannot  choke,  because 
there  is  ample  room  in  the  pharynx  for  even  a  larger  tube.  The 
physician  must  refrain  from  sharing  the  patient's  excitement,  and  by 
calm  demeanor  reassure  him  when  he,  as  is  often  the  case,  protests 
that  he  is  utterly  unable  to  obey  instructions.  Several  attempts  may 
18 


274       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

be  required,  and  these  should  be  made  with  perfect  calmness  and  with- 
out flurry  or  appearance  of  disappointment  on  the  part  of  the  physician. 
In  many  hundreds  of  instances  I  have  rarely  failed.  It  is  a  common 
observation  to  find  some  patients  who  at  first  declared  it  impossible  to 
swallow  the  tube  becoming  so  expert  that  they  execute  the  entire  proc- 
ess without  any  assistance.  Sometimes  an  obstruction  is  met  with 
at  the  cardiac  orifice  which  checks  the  onward  passage  of  the  tube. 
If  an  assistant  will  pour  warm  water  into  the  funnel  at  this  moment, 
the  spasm  will  relax  and  the  tube  pass  steadily  down.  At  times  it  is 
necessary  to  move  the  introduced  portion  back  and  forth.  This,  how- 
ever, should  be  avoided,  because  it  produces  gagging.  It  will  be 
found  that  each  introduction  is  more  free  from  trouble  and  distress. 
The  tube  being  introduced  to  the  line  mark  usually  found  upon  it  (the 
distance,  however,  may  be  measured  in  each  case  by  laying  the  tube 
along  the  curve  of  the  proposed  course  from  the  mouth  to  the  xiphoid 
cartilage),  the  patient,  or,  better,  an  assistant  is  asked  to  hold  it 
lightly  but  securely  near  the  teeth,  the  mouth  being  held  open.  Having 
ascertained  that  the  tube  has  not  entered  the  trachea  (an  accident  which 
I  have  observed),  water  is  now  poured  into  the  tube  through  a  funnel 
connected  with  it.  If  vomiting  ensues,  the  patient  is  quietly  asked  to 
lean  over  the  basin  and  allow  the  vomit  to  flow  out  around  the  tube. 
He  should  be  informed  before  the  beginning  of  the  procedure  of  the 
probability  of  vomiting,  and  should  be  assured  that  he  may  readily  do 
so  without  removing  the  tube.  If  the  irrigation  be  done  too  early  after 
a  meal,  or  if  undigested  food  or  large  quantities  of  tenacious  mucus  ob- 
struct the  fenestra  and  lower  opening,  the  water  should  be  made  to 
flow  from  a  greater  height  by  holding  the  funnel  up.  Sometimes  it 
may  become  necessary  to  remove  the  tube,  clean  it,  and  reintroduce  it. 
This  renders  the  process  more  troublesome,  especially  if  it  is  the  ini- 
tial effort.  Hence  it  is  advisable  to  make  the  first  irrigation  six  or 
seven  hours  after  luncheon,  or  before  breakfast,  when  such  stoppage 
is  not  likely  to  occur.  After  about  a  pint  of  water  has  entered,  the 
funnel,  still  held  firmly,  is  turned  down  into  the  basin,  for  the  pur- 
pose of  forming  a  siphon.  This  should  be  done  quickly,  while  'the 
water  is  still  flowing,  in  order  to  establish  perfect  siphonage.  A 
neglect  of  this  simple  point  may  defeat  the  proper  emptying  of  the 
stomach.  If  the  water  does  not  flow  out  readily,  the  tube  may  be 
introduced  farther  or  withdrawn  a  little.  When  the  stomach  has 
been  well  irrigated  and  the  water  returns  free  from  mucus  or  parti- 
cles of  food,  the  thumb  and  forefinger  should  grasp  the  tube  firmly 
in  front  of  the  patient's  teeth,  and  withdraw  it  rapidly.  Bardeleben 
has  reported  a  case  of  "  Schluck-pneumonie"  from  neglect  of  this 
precaution. 


IRRIGATION. 


275 


During  the  whole  procedure  the  patient  requires  reassurance.  I 
have  sometimes  succeeded  in  inducing  timid  patients  to  make  the  at- 
tempt, after  a  failure,  by  allowing  them,  to  witness  the  introduction 
in  a  well-drilled  person.  This  is  rarely  necessary,  however ;  patience, 


FIG.  56.— The  Intragastric  Resuscitator :  the  gastric  end  of  the  double  tube  covered  by  the  dilatable 

soft  rubber  bag. 

calmness,  reassurance,  gentleness,  and  skill  in  manipulation  and  over- 
coming obstacles  will  surely  succeed  in  nearly  every  case. 

This  description  has  been  somewhat  minute,  because  experience 
convinces  me  of  the  value  of  the  details,  which  the  reader  will  do  well 
to  master. 

Some  modifications  of  this  technique  and  especially  new  apparatus 
have  been  devised  by  Dr.  Fenton  B.  Turck,  who  induces  a  more  stimu- 
lating action  upon  the  mucous  lining  of  the  stomach  by  delivering  a 
needle  spray  instead  of  a  jet  douche,  by  an  ingeniously  constructed 
apparatus.  A  valuable  method  of  applying  hot  water  for  general 
stimulating  effect  in  collapse  is  suggested  by  Dr.  Turck,*  and  named 
by  him  "the  intragastric  resuscitator."  The  accompanying  illustra- 
tion explains  the  apparatus.  The  double  tube  with  attached  rubber 
bag  is  passed  into  the  stomach,  and  a  continuous  current  of  water,  be- 
ginning with  125°  F.  and  gradually  increasing  to  130°  or  135°,  is 
passed  into  and  through  the  rubber  bag,  while  in  situ  within  the 
stomach,  for  half  an  hour.  Turck  claims,  and  cites  a  case  of  Reynaud's 
*The  Lancet,  January  28th,  1399,  p.  216. 


276       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

disease  in  proof,  that  the  exhaustion  produced  by  passing  large  quan- 
tities of  warm  water  directly  into  the  stomach  (which  dilate  the 
splanchnic  vessels)  is  avoided,  and  stimulation  without  exhaustion  re- 
sults ;  also  that  none  of  the  necessary  secretions  are  removed,  and  that 
the  degree  of  temperature  and  quantity  of  water  are  entirely  within 
control. 

Rationale. — The  action  of  lavage  upon  the  stomach  is  chiefly  local. 
The  large  quantity  of  water  flowing  into  the  gastric  cavity  from  a 
height  of  three  or  four  feet,  which  furnishes  nearly  two  pounds'  pres- 
sure, laves  the  mucous  lining  and  removes  tenacious  mucus  from  its 
walls.  Fermenting  material  and  undigested  food  and  detritus  are  re- 
moved by  the  outflowing  stream,  cleansing  and  purifying  the  organ. 
Distention  by  the  rapidly  entering  stream  stimulates  the  muscular 
walls  to  peristaltic  effort  and  thus  aids  the  siphonage.  In  dilatation 
of  the  stomach  very  large  quantities  may  be  retained,  and  the  organ 
may  thus  be  paralyzed;  hence  the  precaution  not  to  exceed  one  pint 
without  making  an  effort  to  remove  it. 

When  cold  water  is  used,  the  effect  is  the  same  as  when  it  is  ap- 
plied on  the  cutaneous  surface — a  neuro-vascular  excitation  causing  con- 
traction and  subsequent  dilatation  of  the  gastric  vessels,  and  a  stimu- 
lus to  the  local  nerves.  This  is  verified  by  some  investigations  by 
Lusini,  *  which  furnish  the  interesting  discovery  that  lavage  produces  a 
general  effect  also  upon  the  system.  These  experiments  were  insti- 
tuted in  patients  suffering  from  chronic  gastric  catarrh,  with  and 
without  dilatation  of  the  stomach,  as  well  as  in  healthy  individuals. 
A  series  of  irrigations  with  from  two  and  one-half  to  twelve  litres  of 
ordinary  water  was  made  before  breakfast,  at  9  A.M.  and  4  P.M. 
Every  observation  was  divided  into  three  periods — before,  during,  and 
after  irrigation,  and  each  person  was  tested  for  seven  days.  The 
quantity  of  urine  was  not  increased,  no  matter  how  large  the  quantity 
of  water  employed.  Absorption  of  water  was  extremely  slight.  The 
acidity  of  the  urine  was  diminished,  not  only  immediately  aftei  the 
irrigation  but  also  for  an  entire  day  subsequently;  sometimes  the 
urine  attained  a  neutral  reaction.  The  quantity  of  chlorides  was 
diminished  in  proportion  to  the  quantity  of  water  poured  in.  The 
phosphates  were  slightly  increased.  In  most  cases  the  daily  quantity 
of  urine  was  diminished  after  lavage,  when  the  latter  was  continued 
for  some  time,  especially  in  gastric  dilatation.  The  N  constituent 
of  the  faeces  was  also  reduced  below  the  normal.  The  weight  was  in- 
creased in  the  healthy  as  well  as  in  those  suffering  from  stomach  troub- 
les. Their  general  condition  was  improved,  appetite  increased,  and 

*  Transactions  of  the  Accademia  di  Fisiocritici  in  Siena,  1896,  quoted  in 
the  Deutsche  Medizinal-Zeitung. 


IRRIGATION.  277 

digestion  was  regulated.  Lavage  exercised  a  favorable  influence  upon 
intestinal  disinfection,  as  evidenced  by  reduction  of  the  indoxy-sulphate 
of  potassium.  Lusini  concludes  that  lavage  improves  the  digestive 
and  absorbing  powers  of  the  digestive  tract  and  favors  the  accumula- 
tion of  nitrogenous  reserve  substances ;  it  also  acts  indirectly  as  an 
agent  for  disinfection  of  the  organism. 

Fenton  B.  Turck  has  reported  *  some  valuable  laboratory  experi- 
ments. Among  his  conclusions  are  the  following :  Extreme  heat  and 
cold  applied  within  the  stomach  or  intestines  produce  marked  splanch- 
nic congestion,  resulting  in  collapse.  After  the  loss  of  a  large  quan- 
tity of  blood,  it  is  possible  to  stimulate  and  resuscitate  by  the  applica- 
tion of  moderate  heat  within  the  stomach  or  colon,  which  is  more  ac- 
tive and  prompt  than  subcutaneous  saline  solution.  Heat  applied  by 
the  intragastric  hot-water  bag  and  double  tube  increases  the  blood 
pressure,  stimulates  cellular  activity,  and  reduces  shock. 

Therapeutic  Indications. — Lavage  is  used  for  diagnostic  as  well  as 
curative  purposes.  Its  value  as  a  diagnostic  agent  in  dyspepsia  has  so 
frequently  come  under  my  observation  that  I  regard  its  diagnostic  impor- 
tance equal  to  its  therapeutic  value.  There  is  no  disease  that  perplexes 
the  physician  more  than  do  the  various  types  of  dyspepsia.  To  diagnos- 
ticate an  ordinary  atony  (gastric  catarrh)  or  a  neurosis  of  the  stomach 
from  other  forms  of  gastric  trouble  is  not  devoid  of  difficulty.  When 
a  case  of  chronic  dyspepsia  presents  itself,  it  is  my  custom  to  bid 
the  patient  eat  a  full  meal  at  12:30  P.M.  and  present  himself  at  5:30 
P.M.  for  exploratory  irrigation  of  the  stomach  with  tepid  water.  The 
stomach  should  be  thoroughly  washed  out,  even  if  several  quarts  of 
water  are  required,  but  no  larger  quantity  than  one  pint  should  be  intro- 
duced at  once.  The  washings  should  be  carefully  inspected,  when  it  will 
be  readily  discovered  if  the  patient  has  masticated  the  food  thoroughly 
and  if  portions  of  food  have  remained  undigested.  Thus  a  clew  will  be 
afforded  the  physician  to  the  actual  digestive  powers  of  the  patient,  and 
the  latter  obtains  a  valuable  guide  for  future  conduct.  If  the  washings 
contain  mucus,  it  is  important  to  distinguish  between  stomach  and 
throat  mucus.  The  former  is  a  thick,  tenacious,  brown  mass,  which 
floats  upon  the  surface  of  the  water  like  the  scum  on  the  surface  of 
a  pond;  the  throat  mucus  is  thin,  transparent,  stringy,  and  may  be 
quite  abundant,  being  the  result  of  irritation  by  the  tube  of  the  pha- 
rynx and  oesophagus.  The  quantity  and  quality  of  the  stomach  mucus 
indicate  with  some  accuracy  the  condition  of  the  gastric  mucous  mem- 
brane. Its  rapid  or  slow  disappearance  under  renewed  irrigations  and 
treatment  indicates  the  character  of  the  disease  affecting  the  mucous 

*  Reprint  from  Proceedings  of  the  American  Gastro-Enterological  Asso- 
ciation, Washington,  D.  C. ,  May,  1900. 


278       THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

lining  and  the  progress  of  the  case  under  treatment,  much  more  relia- 
bly than  any  other  treatment  of  the  usually  hypochondriacal  patient. 

Atony  of  the  Stomach. — In  the  treatment  of  mild  or  recent  cases  of 
gastric  catarrh  in  which  lavage  for  diagnostic  purposes  has  shown  the 
presence  of  tenacious  mucus,  undigested  food,  and  fermenting  mate- 
rial, a  daily  lavage  is  a  valuable  adjunct.  In  cases  of  long-standing 
gastric  catarrh,  the  most  unpromising  type  that  comes  under  the  phy- 
sician's care,  the  diagnosis  may  be  at  once  established,  but  their  treat- 
ment by  irrigation  is  not  so  successful  as  in  those  of  recent  origin. 
As  an  addition  to  hygienic  and  dietetic  management,  lavage  is  useful, 
however,  inasmuch  as  it  frees  the  stomach  thoroughly  from  accumula- 
tions of  fermenting  material  and  tenacious  mucus,  and  prevents  the 
over-distention  by  gases,  which  paralyzes  the  motor  functions  of  the 
gastric  walls  and  forms  an  almost  insurmountable  obstacle  to  recovery. 

The  time  at  which  these  irrigations  are  most  useful  has  been  dis- 
cussed with  much  earnestness  and  even  with  some  acrimony,  so  greatly 
do  observers  differ  upon  this  subject.  Eiegel  and  others  insist  that 
this  lavage  is  most  successfully  applied  at  bedtime,  because  it  enables 
the  stomach  to  be  restored  to  a  nearly  normal  condition,  free  from  fer- 
menting material  and  particles  of  undigested  matter,  during  the  night. 
There  is  doubtless  good  reason  for  his  preference  in  the  fact  that  in 
Germany  supper  is  usually  a  light  meal ;  but  in  this  country,  especially 
in  cities,  where  the  last  meal  is  the  largest  (dinner),  and  is  taken  three 
or  four  hours  before  retiring,  much  good  nutritive  material  would  be 
lost  by  this  practice.  In  this  country,  therefore,  it  is  desirable  to  re- 
sort to  irrigation  in  the  morning,  except  in  cases  which  are  under 
constant  supervision,  in  which  the  interval  between  the  last  meal  and 
the  irrigation  may  be  made  longer  and  the  meal  of  less  substantial 
food.  The  time  must  depend  a  good  deal  upon  the  individual  case. 
When,  for  instance,  we  have  a  case  characterized  by  accumulation  of 
large  quantities  of  tenacious  mucus,  which  interferes  with  digestion 
and  demands  large  quantities  of  water,  I  am  in  the  habit  of  washing 
the  stomach  a  short  time  before  dinner,  directing  the  patient  to  make 
his  luncheon  of  some  light  broth  or  hot  milk  at  noon.  Five  hours 
suffice  for  digestion ;  if  the  stomach  contents  have  not  been  disposed 
of  in  six,  it  is  probable  that  they  will  be  propelled  into  the  bowel  undi- 
gested, and  will,  therefore,  be  lost  to  nutrition.  Hence  a  luncheon  at 
twelve  or  one,  and  lavage  at  six,  are  most  suitable  for  business  men 
and  women  suffering  from  gastric  atony. 

Professor  Fleiuer  *  refers  to  lavage  as  follows :  "  In  almost  all  cases 
lavage  is  of  great  service  to  the  empty  stomach  even  in  the  morning. 

* "  Uebev  die  Diagnostik  und  Behandlung  motorischer  StOrungen  des 
Magens,"  Munchener  niedicinische  Wochenschrift,  No.  43.  1895. 


IRRIGATION.  279 

Regular  irrigations,  which  really  can  be  executed  only  in  institutions, 
produce  an  excellent  appetite.  The  changing  distention  and  emptying 
of  the  stomach  act  upon  the  walls  of  the  stomach  like  local  gymnas- 
tics. Motility  is  rapidly  improved,  atony  disappears,  the  stomach 
empties  more  rapidly,  fermentation  and  abnormal  formation  of  acid 
cease ;  also  nervous  pains  in  the  stomach,  upon  which  irrigation  acts 
like  a  warm  douche,  being  relieved." 

In  malignant  disease  of  the  stomach,  gastric  lavage  often  serves  to 
prolong  life  and  give  comfort.  This  was  illustrated  by  the  case  of  a 
busy  lawyer  under  my  care,  in  whom  the  products  of  decomposition 
produced  an  offensive  odor  in  the  washings  and  were  mingled  with 
such  enormous  quantities  of  mucus  that  six  or  eight  quarts  of  water 
were  required  for  complete  cleansing.  He  had  vomited,  prior  to  treat- 
ment, every  other  day  for  months,  and  thus,  being  partly  freed  from 
the  accumulations,  managed  to  attend  to  his  large  and  exacting  busi- 
ness. There  was  not  a  particle  of  hydrochloric  acid  in  his  stomach, 
according  to  frequent  analysis.  The  motor  power  was  so  far  in  abey- 
ance that  particles  of  food  were  recognized  in  the  washings  twenty- 
four  hours  after  he  had  partaken  of  it.  This  case  was  completely 
relieved  of  symptoms,  requiring  only  biweekly  washings.  It  proved  to 
be  a  case  of  pyloric  stricture  of  malignant  character,  for  which  the  pa- 
tient was  operated  upon  and  to  which  he  finally  succumbed.  Lavage 
served  to  make  life  tolerable  and  to  prolong  it. 

When  the  motor  function  of  the  stomach  is  impaired  without  other 
organic  involvements,  as  in  anaemia  or  other  conditions  which  depreci- 
ate the  general  muscular  and  nerve  tone,  lavage  should  not  be  resorted 
to  habitually.  A  weekly  or  biweekly  evacuation  suffices  for  diag- 
nostic, prognostic,  and  therapeutic  purposes,  while  other  appropriate 
treatment  is  resorted  to  for  the  restoration  of  the  general  condition. 
In  all  atonic  conditions  it  is  a  useful  practice  to  terminate  the  lavage, 
after  thorough  emptying  of  the  stomach,  by  pouring  into  it  six  to  eight 
ounces  ice-water  (40°  F.)  and  siphoning  it  out  immediately. 

Dilatation  of  the  Stomach. — The  complete  emptying  of  the  stomach, 
as  often  as  may  be  indicated,  may  restore  the  contractile  capacity  of 
the  stomach  walls,  just  as  the  catheter  does  in  ischuria  occasionally, 
and  thus  lavage  may  aid  in  restoring  its  lost  shape  and  size. 

In  all  cases  of  this  kind,  not  due  to  actual  stricture  but  simply  to 
gastric  catarrh,  with  excessive  fermentation,  and  mucus,  which  encour- 
ages the  formation  of  butyric  acid,  gastric  irrigation  five  hours  after 
meals,  either  before  dinner  or  breakfast,  is  perhaps  the  most  valuable 
therapeutic  resource  we  have,  if  cautiously  introduced. 

In  nervous  dyspepsia  we  may  be  urged  by  patients  who  have 
already  used  it  to  frequent  irrigation,  on  account  of  the  alleged  gastric 


280        THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHEEAPY. 

fulness  of  which  they  complain ;  it  is  wise  to  resist  these  appeals.  An 
occasional  irrigation  cleanses  the  stomach  of  possible  accumulations, 
rare  though  they  be,  and  exerts  a  psychical  effect  which  is  of  some 
value.  The  products  of  fermentation  require  only  occasional  removal 
in  these  cases.  The  use  of  small  quantities  of  ice  water  in  lavage  acts 
as  a  douche  upon  the  stomach  walls,  and  aids  other  means,  such  as  elec- 
tricity, etc.,  in  restoring  its  tone.  Rosenheim  reports  from  Leyden's 
clinic*  on  the  value  of  douching  the  interior  of  the  stomach  with  fine 
streams  of  warm  water,  plain  or  medicated,  which  are  delivered  with 
considerable  pressure.  He  has  found  a  douche  of  water  of  from  95°- 
110°  F.  an  excellent  calmative  and  gentle  stimulant  in  nervous  dys- 
pepsia, moderate  catarrh,  and  other  stomach  troubles,  which  often 
yielded  in.  a  remarkable  manner  in  a  very  short  time. 

Gastralgia. — The  most  frequent  etiological  factor  of  this  distress- 
ing malady,  when  not  due  to  gastric  ulcer,  is  the  presence  of  fermenting 
remnants  of  undigested  food.  Whether  they  or  some  disturbance  of  the 
nerve  supply  be  the  cause,  an  irrigation  with  water  at  110°  F.  in  large 
quantities  is  one  of  the  most  valuable  measures.  The  following  de- 
scription of  a  case  treated  in  KussmauPs  clinic  illustrates  the  value  of 
this  simple  procedure.  "A  woman,  twenty-two  years  of  age,  suffered 
after  three  years  of  dyspepsia  from  agonizing  gastralgia,  which  failed 
to  yield  to  all  remedies,  including  electricity,  wet  compresses,  blisters, 
etc.,  and  was  relieved  only  by  morphine.  Becoming  habituated  to  the 
latter,  she  gave  up  work,  and  entered  the  clinic  in  a  miserable  condition 
— feeble,  emaciated,  pale,  her  abdominal  wall  covered  by  cicatricial 
knots  from  hypodermatics,  etc.  Diet,  rest,  etc.,  were  unavailing;  mor- 
phine was  still  required.  Her  stomach  was  now  irrigated  with  warm 
water  every  morning,  while  empty.  The  water  returned  almost  clear 
and  a  little  acid.  This  was  continued  with  relief  of  pain  and  renewal 
of  appetite.  Carbonized  water,  mixed  with  plain  water  at  100°  F.,  was 
now  substituted,  two  or  three  litres  being  used.  In  three  Aveeks  she 
could  eat  beefsteak,  etc.,  and  take  a  walk.  Warm  baths  at  night,  of 
ten  minutes'  duration,  were  now  administered  with  great  benefit.  The 
morphine  injection  gradually  became  less  necessary.  To  aid  in  obtain- 
ing spontaneous  actions  of  the  bowels,  faradization  was  produced  by 
introducing  a  wire  electrode  through  the  tube  into  the  half -filled  stom- 
ach, and  placing  another  electrode  upon  the  outside  for  five  minutes.  In 
four  weeks  she  was  entirely  restored."  Incases  in  which  the  soothing 
effect  of  warm  irrigation  is  desired,  it  is  self-evident  that  the  warm 
water  should  be  allowed  to  remain  in  the  stomach  for  several  minutes. 
Heus. — From  whatever  cause  it  may  originate,  intestinal  obstruction 
presents  one  of  the  most  terrible  exigencies  of  the  physician's  life.  It 
*  Therapeutische  Wocbenschrift,  August,  1892. 


IRRIGATION.  281 

creeps  upon  the  patient  with  slow  but  inexorable  grasp,  and  one  remedy 
after  another  is  exhausted,  until  collapse  ensues.  Happily  the  mod- 
ern physician  does  not  trust  so  long  to  the  hope  of  spontaneous  relief 
as  did  his  predecessors.  During  the  past  thirty-five  years  of  the  au- 
thor's observation,  he  has  never  encountered  a  disease  that  has  so  de- 
ceived and  baffled  him  with  false  hope.  To-day  surgical  technique  is  so 
perfect  that  an  abdominal  section  has  lost  its  terrors,  and  the  surgeon 
is  more  frequently  invited  to  step  in  than  formerly.  Nevertheless,  we 
wait  too  long,  adhesions  occur,  the  patient's  strength  wanes,  and  when 
collapse  ensues  our  surgical  colleagues  too  are  helpless.  It  is  fortunate 
that  we  have  in  gastric  lavage  not  only  a  palliative  for  the  patient's 
sufferings,  which  no  one  can  realize  who  has  not  stood  at  the  bedside 
of  such  a  patient,  but  a  remedial  agent  which  has  been  effective  in 
many  cases  reported  by  Kussmaul,  Leube,  Henoch,  Ewald,  Cursch- 
man,  Senator,  and  others.  Indeed,  gastric  lavage  has  proven  so  valu- 
able as  a  palliative  in  the  author's  hands  that  a  note  of  warning  not 
to  trust  too  long  to  this  measure  may  be  instructive.  In  a  case  occur- 
ring in  my  service  in  the  Manhattan  Hospital,  the  stercoraceous  vom- 
iting and  the  terrific  straining  incident  to  a  case  of  ileus  were  so  thor- 
oughly removed  by  two  gastric  irrigations  that  the  house  staff  was 
lulled  into  a  false  sense  of  security,  from  which  the  sudden  collapse  of 
the  patient  aroused  it.  Laparotomy  was  done  by  Dr.  Wilkie,  who 
found  several  bands  constricting  the  small  intestine  and  one  invagina- 
tion. 

The  first  case  of  ileus  successfully  treated  by  gastric  lavage  was 
reported  by  Kussmaul.  The  patient  was  admitted  in  March,  1882, 
after  he  had  been  unsuccessfully  treated  by  all  the  usual  methods  for 
eight  days.  The  stomach  was  thoroughly  washed  out,  feculent  masses 
were  evacuated,  and  the  irrigation  was  repeated  every  three  or  four 
hours  until  the  water  came  away  clear.  Then  the  patient  fell  asleep 
for  the  first  time,  and  on  awakening  passed  a  thin  yellow  stool.  No 
further  treatment  was  necessary;  recovery  was  complete  in  five 
weeks. 

A  second  case  occurred  a  year  later.  Here,  again,  all  remedies  had 
been  exhausted  for  nine  days  without  result.  Laparotomy  was  deter- 
mined upon,  but  Professor  Lticke,  the  surgeon,  requested  Kussmaul 
to  see  the  patient  before  operation.  One  large  irrigation  of  the  stom- 
ach removed  immense  masses  of  feculent  matter,  and  was  followed  by 
sleep,  which  had  been  denied  the  patient  even  under  large  doses  of 
morphine. 

The  publication  of  these  cases  aroused  so  much  attention  that  gas- 
tric lavage  was  at  once  added  to  the  remedies  for  ileus. 


282        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

In  an  article  by  Hassenclever  *  this  author  gives  the  histories  of  six 
cases,  of  which  five  were  greatly  relieved  by  irrigation  of  the  stomach 
and  one  was  saved.  He  regards  this  procedure  as  a  decided  enrich- 
ment of  our  therapeutic  resources  in  ileus. 

In  a  discussion  of  Professor  Bardeleben's  paper  on  "  Ileus"  at  the 
Berlin  Medical  Society,  f  Professor  Henoch  said  that,  inasmuch  as  an 
exact  diagnosis  of  ileus  is  often  impossible,  it  is  the  duty  of  the  medi- 
cal attendant  to  resort  to  gastric  lavage.  He  had  observed  only  one 
case,  but  the  result  was  so  remarkable  that  it  made  a  strong  impression 
upon  him.  He  would  therefore  always  regard  it  as  a  great  sin  of  omission 
not  to  practise  lavage  in  the  early  stages  of  this  malady.  Henoch  ad- 
vises not  to  await  collapse  before  an  operation  is  resorted  to,  but  to  do 
the  latter  if  the  stomach  irrigation,  administered  several  times,  has 
failed  to  produce  the  passage  of  flatus  or  fseces. 

Professor  Senator  agreed  with  Henoch,  and  met  Surgeon  Hahn's 
objection  to  the  irrigations  on  the  ground  of  their  being  only  pallia- 
tives by  the  logical  argument  that  opium  and  morphine  would  have  to 
be  rejected  on  the  same  ground,  and  thus  the  operation  would  be  done 
without  trying  any  other  measures.  He  advises  that  irrigations  be 
used  every  five  or  eight  hours.  If  the  condition  of  the  patient  grows 
worse,  operation  should  not  be  delayed. 

Dr.  J.  Wolff  thought  that,  despite  the  fact  that  ileus  is  rarely 
cured  by  irrigations,  the  latter  should  never  be  neglected,  "  because  in 
the  most  pitiable  cases  they  produce  so  delightful  an  effect,  even 
though  transient  in  most  cases,  that  humanity  alone  demands  this  relief 
for  our  patients.  Moreover,  the  surgical  demand  for  cleanliness  is 
fulfilled  by  cleaning  the  stomach  of  faecal  matter,  and  the  chances  of 
recovery  from  an  operation  are  increased  by  the  comfort  to  which  the 
patient  is  transported  by  the  irrigations.  Even  a  patient  suffering 
from  carcinomatous  stenosis,  who  had  vomited  fseces  for  three  days, 
was  placed  in  such  a  comfortable  condition  that  she  retained  large 
quantities  of  bouillon,  milk,  and  wine  for  several  hours. " 

The  author's  observations  confirm  this  statement  and  induce  him  to 
urge  this  symptomatic  lavage  most  earnestly  in  these  desperate  cases. 
Curschman  J  reports  one  hundred  and  five  cases  of  ileus,  of  which 
thirty-five  cases  were  cured.  Stomach  irrigation  proved  of  extraor- 
dinary value  in  many  cases. 

Pollok  reported  in  detail  §  seven  cases  of  ileus  treated  by  lavage. 

The  reports  of  a  large  number  of  cases  of  acute  intestinal  obstruc- 

*  "Die  Behandlung  des  Ileus  mit  Magenausspiilung,"  Berliner  kliniscbe 
Wochenschrift,  November  5th,  1885. 

f  Berliner  klinische  Wochenschrift,  1885,  p.  458. 
i  Berliner  klinische  Wochenschrift,  1885,  p.  386. 
§  Wiener  medizinische  Wochenschrift,  No.  51,  1892. 


IRRIGATION.  283 

tion  which,  have  been  relieved  by  lavage,  combined  or  not  with  intes- 
tinal irrigations,  may  be  found  in  our  literature.  Pollok  refers  to 
Wignolle,  who  cites  ten  cases  with  nine  recoveries  from  prolonged  ob- 
struction (pseudo-estranglenient) ;  in  these  lavage  proved  palliative 
and  curative. 

Rationale. — The  observations  of  Kussmaul,  Oser,  Ewald,  and  others 
would  seem  to  establish  that  the  favorable  action  of  lavage  in  intesti- 
nal obstruction  depends  upon  removal  of  feculent  matter  from  the 
stomach,  which  by  reason  of  the  insufficiency  of  the  pyloric  orifice  per- 
mits a  continuous  flow  from  the  intestine  into  the  stomach  and  thence 
out  through  the  tube.  Thus  the  pressure  above  the  constricted  part  of 
the  intestine  is  relieved,  which  favors  spontaneous  reposition.  The 
great  distention  of  the  stomach  and  bowels  by  a  feculent  mass  to  which 
they  are  unaccustomed  may  induce  an  abdominal  irritation  of  the 
splanchnic  fibres.  Intestinal  activity  is  inhibited  by  reason  of  the 
relaxation  of  the  muscular  coats.  Lavage  permits  peristaltic  action  to 
be  restored;  abdominal  pressure  is  relieved  by  it  and  the  circulation  of 
the  affected  parts  is  restored.  That  the  removal  of  the  stagnant  con- 
tents of  the  stomach  and  upper  intestines  is  sufficient  to  open  the  canal 
below  is  demonstrated  by  those  cases  in  which  enterostomy  of  the  ileum 
has  served  to  open  the  intestinal  canal  lying  obstructed  below  it,  and 
by  those  cases  in  which  prolonged  obstruction  was  suddenly  removed 
after  enormous  quantities  of  fecal  matter  had  been  vomited. 

Krimmel  has  shown*  by  observations  on  the  living  subject,  after 
the  abdominal  cavity  was  opened,  that  lavage  causes  peristaltic  action 
in  the  stomach  which  extends  to  the  duodenum  and  jejunum,  giving 
evidence  cf  a  reflex  effect. 

There  is  no  doubt,  therefore,  that  the  palliative  and  curative  action 
of  lavage  maybe  explained  on  as  rational  principles  as  that  of  any  other 
remedy  or  remedial  agent. 

From  these  data,  which  the  author's  observations  amply  confirm, 
it  is  evident  that  no  case  of  intestinal  obstruction  may  be  regarded  as 
properly  treated  unless  gastric  lavage  every  three  hours  has  been  tried 
several  times.  It  is  important,  however,  not  to  trust  too  long  to  the 
apparent  cessation  of  the  symptoms  and  the  great  relief  afforded  to  the 
patient.  A  surgeon  should  be  called  in  early  to  watch  the  case  and 
interfere  at  the  proper  moment  if  the  faeces  appear. 

One  point  in  the  technique  of  lavage  in  these  cases  is  very  impor- 
tant— the  firm  pinching  of  the  tube  and  its  rapid  withdrawal  to  avoid 
the  entrance  of  faecal  or  other  matter  into  the  larynx.  Vomiting  has 
produced  schluckpneunionie  in  such  cases,  according  to  Bardeleben. 

Cholelithiasis. — In  the  fearful  pain  sometimes  occurring  in  this 
*  Deutsche  medicinische  Wochenschrift,  1890. 


284        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

disease,  lavage  has  been  found  very  useful.  In  a  recent  case  in  the 
author's  family,  not  only  was  relief  obtained,  but  a  number  of  small 
calculi  were  seen  in  the  stools  on  the  following  morning  after  lavage. 

Kussmaul  has  reported  two  cases  in  which  similar  results  were 
obtained. 

The  removal  of  fermenting  material,  mucus,  and  undigested  food 
from  the  stomach  doubtless  contributes  much  to  the  comfort  of  the 
patient,  and  prevents  the  formation  of  gall  stones  by  keeping  the  duct 
unobstructed.  Despite  clinical  observation,  however,  it  is  difficult  to 
account  for  its  effect  on  the  passage  of  gall  stones. 

Forced  feeding  and  medication  may  be  accomplished  by  lavage 
through  the  nose.  I  have  introduced  a  large  dose  of  castor  oil  and  later 
calomel  into  the  stomach  of  a  child  suffering  from  eclampsia  with 
intervening  coma,  by  pushing  a  Jacques  velvet-eye  catheter  through  the 
nose  into  the  stomach.  The  same  method  may  be  pursued  for  feeding 
or  medicating  refractory  children  and  insane  adults. 

ENTEKOCLTSIS. 

This  is  a  term  applied  to  the  introduction  of  large  quantities  of 
water  into  the  large  intestines  by  means  of  long  rectal  tubes  adapted 
to  the  purpose.  This  procedure  is  also  known  as  intestinal  irrigation, 
because  the  water  introduced  is  intended  to  act  chiefly  as  a  distending 
and  cleansing  agent,  to  be  again  ejected  by  the  patient.  Such  an  irri- 
gation cannot  be  accomplished  by  the  ordinary  enema  of  warm  water, 
which  usually  consists  of  smaller  quantities  introduced  by  a  short  rectal 
tube,  which  act  as  an  irritant  and  produce  an  immediate  evacuation. 

Technique. — The  largest  Nelaton  catheter  or  a  small  lavage  rubber 
tube  or  a  horse  catheter,  with  firm  walls,  having  been  thoroughly 
cleaned  with  boiling  water,  is  attached  to  a  clean  fountain  syringe  con- 
taining one  or  more  quarts  of  water  that  has  been  boiled  for  half  an 
hour,  and  in  which  half  a  drachm  of  chloride  of  sodium  has  been  dis- 
solved for  the  purpose  of  rendering  it  less  irritating  to  the  mucous 
membrane.  The  patient  is  placed  on  his  back  on  a  bed  or  a  sofa,  or,  if 
an  infant  or  child,  upon  the  abdomen  in  an  attendant's  lap,  upon  which 
a  piece  of  rubber  cloth  has  been  laid,  covered  by  a  warm  towel.  The 
lower  part  of  the  rubber  cloth  is  placed  within  a  small  tub,  to  act  as  a 
gutter  for  the  returning  outflow.  The  floor  should  also  be  protected 
against  the  usual  projectile  gush  of  the  latter.  The  tube,  anointed 
with  vaseline  and  firmly  held  between  the  thumb  and  index  finger  of 
the  right  hand,  is  introduced  into  the  anus,  water  having  previously 
been  allowed  to  flow  until  it  runs  warm,  and  gently  but  firmly  pushed 
into  the  intestinal  canal.  It  is  well  to  use  the  two  fingers  of  the  left 


IRRIGATION.  285 

hand  as  a  guide  or  railway  for  the  soft  and  yielding  tube,  and  to  hold 
the  latter  with  the  right  hand  only  half  an  inch  from  the  anus  in  order 
to  give  firmness  and  support.  Whenever  the  tube  meets  an  obstruction 
it  should  be  withdrawn  a  little  and  gently  persuaded  to  pass  upward. 
By  allowing  the  water  to  flow  and  distend  the  bowel,  introduction  is 
sometimes  greatly  facilitated.  Remembrance  of  this  point  has  fre- 
quently saved  me  the  mortification  of  abandoning  the  introduction. 
Sometimes  the  tube  is  more  readily  introduced  when  disconnected  from 
the  syringe.  When  the  upper  part  has  reached  the  transverse  colon, 
or  cannot  be  introduced  farther,  it  is  held  quietly  until  about  a  quart 
of  water  has  been  passed.  There  will  be  little  distention,  because  the 
pressure  of  the  child's  body  upon  the  nurse's  lap  will  usually  aid  in 
expelling  the  water  as  rapidly  as  it  is  introduced.  If  it  does  not 
return  it  may  be  allowed  to  run  out  through  the  catheter,  which  must 
be  detached  for  the  purpose ;  older  children  may  be  placed  upon  the 
commode. 

The  procedure  is  almost  painless.  Very  young  infants  will  cry, 
but  older  children  require  to  be  quieted  by  being  amused  with  play- 
things. Care  should  be  taken  to  avoid  doubling  up  of  the  catheter  in 
the  rectum.  This  is  evidenced  either  by  entire  stoppage  of  the  flow  or 
by  its  immediate  return  through  the  anus.  It  is  usually  due  to  tenes- 
mus.  It  is  better  to  desist  than  to  make  repeated  efforts  to  overcome 
this  doubling  up. 

Dr.  Robert  C.  Kemp*  has  devised  a  double-current  rectal  irriga- 
tor,  for  which  he  claims  the  advantage  of  completely  plugging  the 


FIG.  57.— Kemp  Double-Current  Rectal  Irrigator. 

anus,  allowing  the  water  and  gas  to  run  off  readily,  thus  preventing 
overdistention  of  the  bowels.  Although  it  is  somewhat  complicated, 
its  ingenious  construction  admits  of  its  being  readily  cleaned. 

Rationale  of  Enter ocly sis. — Fluids  introduced  into  the  rectum,  with 
careful  occlusion  of  the  anus,  and  aided  by  the  position  of  the  patient 
and  sufficient  pressure,  not  only  fill  the  large  intestines,  but  under  cer- 
tain conditions  may  also,  as  some  authors  have  shown,  pass  through 
the  ileo-csecal  valve  and  irrigate  the  ileum.  Among  the  best  observa- 
tions on  the  subject  may  be  cited  those  of  Generisch.f  He  found  that 

*New  York  Medical  Journal,  March  13th,  1897. 

t  "Wiener  medizinische  Presse,  No.  39,  1893. 


286        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

while  neither  water,  oil,  nor  mercury  can  be  made  to  pass  from  the 
oesophagus  through  the  uninjured  intestinal  canal  of  an  adult  dead  sub- 
ject, through  the  anus,  the  result  of  inverting  the  flow  is  quite  differ- 
ent. The  ileo-csecal  valve  is  easily  penetrated  under  moderate  pressure; 
water  flowing  from  a  height  of  from  seventy  to  eighty  centimetres  can 
be  made  to  pass  into  the  stomach  and  even  through  the  mouth.  The 
capacity  of  the  digestive  canal  varies  greatly,  the  large  intestine  ac- 
commodating about  three  litres,  and  the  stomach  and  small  intestine 
about  the  same  quantity;  i.e.,  eight  or  nine  litres  would  fill  the  en- 
tire gastro-intestinal  canal.  Generisch  has  convinced  himself  repeat- 
edly that  in  the  living  body  water  may  be  propelled  from  the  anus  to 
the  mouth.  Usually  abundant  vomiting  begins  after  the  seventh  litre 
has  passed  into  the  rectum,  and  if  the  irrigation  is  kept  up  vomiting 
continues  until  the  tube  is  removed,  when  the  fluid  begins  to  pour 
from  the  anus  also,  only  two  or  three  litres  remaining. 

Aldor  *  reviews  this  subject  because  many  discredited  the  fact  that 
fluid  readily  passes  from  the  anus  to  the  ileo-caecal  valve.  Aldor  claims 
to  have  demonstrated  the  presence  of  the  tube  in  the  colon  by  a  Roent- 
gen picture.  Boas  insists  also  that  even  low  irrigations  send  fluids  to 
the  ileo-caecal  valve,  and  confirms  his  statement  by  a  case  in  which 
fluid  injected  into  the  rectum  escaped  through  a  colostomy  wound. 
Johnstone,  of  Washington,  D.  C.,  also  states  that  he  has  observed 
colored  fluid  forced  into  the  rectum  under  gentle  pressure  escape  in 
half  a  minute  through  a  fistulous  opening  in  the  right  iliac  region. 

Enteroclysis  is  contraindicatedin  cardiac  disturbances,  arterio-sclero- 
sis,  and  advanced  pulmonary  disease.  It  is  impracticable  when  pro- 
nounced strictures  exist  in  the  tract;  also  in  strangulated  hernia,  and 
in  tuberculous  or  typhoid  ulcerations  of  the  intestines,  for  obvious 
reasons. 

Increase  of  peristalsis  has  been  proved  by  Horvath's  experiments; 
he  sent  streams  of  water  of  from  66°-105°  F.,  progressively  increased, 
through  the  canal,  f 

The  vulnerability  of  the  inflamed  intestine  to  pressure  has  been  tested 
by  Muller.  J  From  five  experiments  on  living  dogs  and  on  one  dead  in- 
fant he  reached  the  conclusion  that  it  is  almost  impossible  to  rupture  an 
inflamed  bowel  even  if  obstructed.  Before  rupture  occurs  the  contrac- 
tion of  the  sphincter  muscle  is  overcome  and  the  water  is  either 
expelled  or  escapes  gradually  through  the  ileo-csecal  valve  into  the 
small  intestine  and  into  the  stomach,  whence  it  may  be  expelled  by 
vomiting.  One  experiment  showed  that  even  in  a  normal  state  of  the 

*  Berliner  klin.  Wochenschrift,  August  21st,  1905. 
f  Malbranc :  Berliner  klinische  Wochenschrift,  1878. 
j  Prize  Essay,  Therapeutic  Gazette,  1893. 


IRRIGATION.  287 

ileo-caecal  valve  irrigation  of  the  small  intestine  is  not  always  possible. 
Five  other  experiments  proved  the  permeability  of  the  small  intestine. 

The  action  of  water  flowing  through  the  intestinal  canal  is  chiefly 
mechanical,  i.e.,  it  removes  the  materials  of  decomposition  and  patho- 
genic elements,  which  are  known  to  cause  and  maintain  many  cases 
of  diarrhoea  and  dysentery.  If  the  fluid  enters  only,  as  is  in  most 
instances  the  case,  the  large  intestines,  peristalsis  in  the  smaller  intes- 
tines is  evoked  and  the  flow  of  bile  is  increased. 

Dr.  Fenton  B.  Turck  presented  to  the  section  on  Practice  of  the 
American  Medical  Association,  June,  1899,  an  essay  on  "Colonic 
Lavage,"  in  which  he  claims  for  the  introduction  of  hot  and  cold  water 
into  the  colon  reflex  stimulation  of  the  vasornotor  centres.  The  blood 
pressure  is  raised,  the  kidneys  are  stimulated,  the  hepatic  function  is 
increased,  and  leucocytosis  is  induced.  There  seems  to  be  indeed  a  gen- 
eral acceleration  of  the  metabolism,  a  general  cell  activity.  He  applies 
intestinal  irrigation  with  the  hips  elevated,  introduces  water  at  122° 
F.,  about  a  quart  at  a  time,  four  times  in  succession,  each  being  allowed 
to  run  off,  and  increasing  the  temperature  gradually  to  131°  F.  After 
the  last  water  has  been  passed  in  the  toilet  room,  the  patient  receives 
a  brief  irrigation  of  water  at  41°  F.  The  author  cites  experiments  on 
animals  to  show  that  in  the  course  of  five  minutes  the  heart  beats 
become  faster  until  the  water  temperature  is  raised  to  131°  F.,  which 
slows  the  pulse  and  increases  blood  pressure,  until  the  peripheral  sur- 
faces (skin)  are  heated,  when  the  pulse  again  becomes  rapid  and  blood 
pressure  is  reduced.  The  latter  is  prevented  by  using  cold  water. 
There  are  increased  leucocytosis  and  a  total  increase  of  blood  cells  after 
several  weeks'  treatment.  In  a  number  of  patients  the  general  tem- 
perature was  increased  by  colonic  lavage  at  131°  F. ;  there  occurs  in- 
creased peristalsis  at  this  temperature,  but  not  at  118°  F. ;  women 
complain  of  pains  like  those  of  labor.  If  injections  at  131°  F.  are  con- 
tinued long  and  repeated,  the  motor  power  of  the  stomach  is  also  en- 
hanced. Irrigation  with  water  at  104°  to  113°  F.  produces  no  im- 
mediate secretion  of  urine,  but  water  at  131°  F.  produces  it  in  three 
minutes. 

The  idea  that  cold-water  irrigations,  as  practised  by  Krull  in  cases 
of  jaundice,  increase  hepatic  action  has  been  demonstrated  to  be  erro- 
neous by  Stadelmann  *  and  his  demonstration  is  confirmed  by  others. 
While  investigating  the  action  of  cholagogues,  Stadelmann  incidentally 
endeavored  to  ascertain  the  effect  of  enteroclysis.  He  correctly  esti- 
mates the  good  effect  of  enteroclysis  in  icterus,  cholelithiasis,  and 
intestinal  disturbances  as  due  entirely  to  the  removal  of  decomposing 

*Therapeutische  Monatshefte,  1891,  Nos.  10  and  11. 


288       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

and  irritating  matters,  hence  to  a  cleansing  and  disinfecting  action, 
and  not  to  a  cholagogue  action. 

Diuretic  Action. — Dr.  W.  E.  Forest*  offers  an  interesting  series  of 
observations  made  upon  himself,  to  show  that  enteroclysis  produces  a 
decided  diuretic  action. 

"  A  large  number  of  experiments  were  made,  all  going  to  prove  that 
a  flushing  of  the  colon  with  hot  water,  followed  by  an  injection  of  from 
a  half-pint  to  a  pint  of  hot  water  that  is  retained,  is  a  quick,  safe,  and 
powerful  means  to  stimulate  the  kidneys  into  action.  This  method  is 
a  more  powerful  diuretic  than  any  drug.  The  only  precaution  to  be 
used  in  order  to  retain  the  hot  water  is  immediately  to  lie  down  for  a 
half -hour  after  receiving  the  injection. 

"  The  outcome  of  these  experiments  proved,  first,  that  from  twelve 
to  twenty  ounces  of  warm  or  hot  water  can  be  retained  at  one  time  in 
the  colon,  and  that  all  of  this  will  be  absorbed  into  the  blood ;  second, 
that  the  normal  amount  of  urine  secreted  by  the  kidneys  in  twelve 
hours  may  be  more  than  doubled  by  means  of  such  retained  injec- 
tions; third,  that  the  mere  flushing  of  the  colon  with  a  large  quan- 
tity of  hot  water  (two  quarts  at  least,  at  one  injection)  powerfully 
stimulates  the  action  of  the  kidneys.  Part  of  this  effect  is  due  to 
the  internal  application  of  heat,  and  part  to  some  of  the  water  being 
absorbed." 

Enteroclysis  has  been  found  of  great  benefit  in  the  treatment  of  all 
kinds  of  fevers.  Professor  Cantani's  plan  of  large  cold  enemas  has 
not  given  the  same  good  results  that  warm  or  hot  enemas  have.  As 
both  Debove  and  Cantani  claim  that  most  of  the  good  effect  of  the  in- 
ternal use  of  water  in  fevers  is  due  to  the  increased  elimination  through 
the  kidneys,  it  is  fair  to  assume  from  the  experiments  given  that  a  very 
important  auxiliary  in  these  cases  to  the  internal  bath  by  the  mouth  is 
the  internal  hot  bath  by  the  colon. 

Forest  also  gives  the  details  of  a  case  of  acute  nephritis  which  is 
of  value  in  demonstrating  this  diuretic  effect.  He  insists  that  in  all 
cases  in  which  the  water  is  to  be  retained  the  colon  should  first  be 
washed  out  by  a  large  warm  injection. 

The  influence  of  injections  into  the  rectum  and  colon  upon  the 
organism  has  been  studied  by  Dr.  Robert  C.  Kemp,  in  experiments 
conducted  at  the  physiological  laboratory  of  the  College  of  Physicians 
and  Surgeons. 

These  careful  experiments  show  clearly  that  the  heart  may  be 
stimulated  by  the  temperature  of  the  irrigation,  as  it  is  in  water-drink- 
ing; and  that  the  urinary  secretion  is  increased  by  reason  of  the  en- 
hanced blood  pressure,  which  ensues  at  once  in  the  kidneys,  but  also  by 
direct  absorption  of  fluid,  which  occurs  later. 

*  Medical  Record,  September  19th,  1891. 


IRRIGATION.  289 

Therapeutic  Indications — Infantile  Diarrhoea. — The  summer  diar- 
rhoea of  infants  offers  an  excellent  field  for  enteroclysis.  If  the  tech- 
nique be  mastered  and  properly  executed,  no  other  remedy  equals  in- 
testinal irrigation  in  removing  bacteria,  soothing  the  suffering  child, 
and  promoting  a  rapid  convalescence.  This  subject  is  fully  treated  in 
the  clinical  portion  of  the  work. 

Catarrhal  Jaundice. — The  author  has  found  an  excellent  adjunct  in 
the  treatment  of  catarrhal  jaundice  in  irrigation  of  the  large  intestine 
with  cold  water.  He  was  led  to  its  application  in  this  disease  by  the 
publication  of  Dr.  Krull,  who  treated  eleven  cases  of  catarrhal  jaun- 
dice by  simple  cold-water  irrigations  of  the  intestines.  After  failure 
with  other  treatment,  which  almost  invariably  had  included  the 
Carlsbad  waters,  these  irrigations  succeeded,  first,  in  relieving  the  con- 
stipation, and,  later,  in  re-establishing  the  hepatic  norm.  Dr.  Lowen- 
thal  reports*  forty-one  cases  of  catarrhal  jaundice,  of  which  all  but  one 
demonstrated  good  and  rapid  effects  from  intestinal  irrigations.  Four 
irrigations  of  one  or  two  quarts  at  a  temperature  varying  from  54°  to 
64°  F.,  increasing  three  degrees  daily  (one  quart  sufficing  for  children), 
were  needed  on  an  average  for  each  case.  In  all  the  cases  faecal  evacu- 
ations, sometimes  diarrhoea,  followed  the  irrigations ;  these  ceased  if 
the  succeeding  irrigation  was  of  a  somewhat  higher  temperature. 
Gray  or  colorless  clay-like  masses  were  evacuated  after  the  first  treat- 
ment; after  the  third  the  faeces  became  slightly  yellowish,  and  after 
the  fourth  usually  brown.  Gastric  pains  and  oppression,  headache, 
etc.,  ceased,  and  appetite  returned;  the  icteric  hue  disappeared  once 
after  the  first,  twice  after  the  second  irrigation.  Pruritus,  in  seven 
cases,  disappeared  after  from  the  second  to  the  fourth  treatment.  The 
skin  began  to  clear  up,  but  continued  dark  for  a  long  time. 

Other  reports  of  similar  results  are  found  in  recent  literature,  con- 
firming the  value  of  this  hydriatric  measure,  so  that  it  may  be  regarded 
as  established. 

I  can  testify  from  personal  experience  to  its  beneficial  effect  in 
catarrhal  jaundice,  and  to  its  failure  in  jaundice  from  gall  stones.  Con- 
trary to  Krull' s  method,  I  have  begun  with  tepid  water  and  reduced  its 
temperature  daily,  and  this  method  has  recently  been  approved  by 
Stadelmann,  who  has  investigated  the  "  cholagogue"  action  of  these 
irrigations.  Once  in  twenty-four  hours,  after  the  bowels  have  been 
evacuated,  either  normally  or  by  enema,  I  order  the  patient  placed  in 
the  knee-elbow  position;  from  one  to  two  quarts  of  water  of  70°  F.  are 
poured  into  the  rectum  from  a  fountain  syringe.  The  patient  is  induced 
to  retain  the  fluid  as  long  as  possible.  On  the  following  day  the  tem- 

*  Berliner  klinische  Wochenschrif  t,  1886. 
19 


290        THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

perature  of  the  water  is  decreased  two  degrees,  and  this  decrease  is  coii- 
tinued  until  60°  F.  is  reached.  From  two  to  six  irrigations  are  suf- 
ficient to  produce  the  desired  result.  In  my  own  experience  the  gastric 
and  hepatic  pains  ceased  after  the  first  injection,  appetite  soon  returned, 
and  jaundice  disappeared  more  or  less  rapidly,  but  that  most  distress- 
ing symptom,  pruritus,  was  not  relieved. 

Dr.  Robert  C.  Kemp,  who  has  done  so  much  for  the  perfection  of 
rectal  irrigation,  its  rationale,  and  its  clinical  applications,  offers  the 
following  deductions  from  his  observations  for  clinical  purposes : 

When  increase  of  pulse  tension  is  to  be  avoided  in  irrigations,  the 
temperature  of  the  water  should  be  101°-104°. 

When  a  rapid  increase  of  pulse  tension  is  desired,  together  with 
improvement  of  cardiac  action,  rectal  irrigation  at  110°,  gradually  in- 
creased to  120°  F.,  is  advisable. 

Cold  irrigation,  being  a  temporary  stimulant,  increases  blood  pres- 
sure, but  later  depresses.  Hence  it  should  be  employed  with  caution. 
Irrigation  with  cold  water  is  dangerous  when  prolonged.  Low  irriga- 
tion is  useful  in  proctitis,  prostatitis,  etc. 

In  hemorrhage,  irrigation  at  1103-120°  secures  the  most  rapid 
result,  improves  the  pulse,  and  relieves  shock. 

In  duodenal  jaundice,  cold  high  irrigation  for  a  very  short  period, 
alternated  with  hot  irrigation  with  the  glass-tube  irrigator,  as  suggested 
by  Dr.  Minor,  has  proved  valuable,  as  well  as  in  chronic  constipation. 

Asiatic  Cholera. — In  this  disease,  which  has  baffled  the  most  skil- 
fully devised  medication,  enteroclysis  has  proved  of  great  service.  It 
was  brought  into  prominence  in  the  epidemic  of  1892,  by  the  efforts  of 
Dr.  Elmer  Lee,  an  American  physician  who  visited  Kussia,  Hamburg, 
and  other  epidemic  centres  for  the  purpose  of  demonstrating  its  value. 
Dr.  Lee's  method,  with  an  illustration  of  the  ingenious  apparatus  de- 
vised by  him,  are  described  in  the  article  on  "  Asiatic  Cholera". 

Uraemia  and  Renal  Insufficiency. — In  acute  conditions  with  rapid 
and  feeble  pulse,  irrigation  at  110°-120°  produces  rapid  improvement; 
renal  secretion  is  started  up ;  profuse  sweating  and  bowel  action  often 
follow.  Irrigations  have  been  given  by  Drs.  Egbert  Grandin,  William 
H.  Thomson,  and  others  for  forty  minutes,  and  repeated  every  four 
hours  with  good  results.  In  one  of  Dr.  Thomson's  cases  the  urine, 
previously  scanty,  was  increased  to  forty  ounces  and  a  pleuritic  effu- 
sion was  absorbed.  In  suppression  with  uraemia,  accompanied  by  high 
tension  and  pyrexia,  Dr.  Kemp  has  observed  rapid  increase  of  renal 
secretion,  bowel  action,  and  sweating,  with  decrease  of  tension,  a  re- 
sult which  my  own  observation  has  verified  in  a  recent  case. 

Cold  enemala  and  irrigation  are  regarded  by  Dr.  Kemp  as  danger- 
ous in  renal  diseases. 


IRRIGATION.  291 

Typhoid  Fever. — Intestinal  irrigations  with  cold  water  have  been 
recommended  by  Cantani  for  cooling  the  body.  But  there  is  another 
indication  which  bids  fair  to  secure  valuable  results — the  cleansing  of 
the  intestinal  canal.  Dr.  T.  J.  Schuell  presents  in  the  New  York 
Medical  Journal  of  September  2d,  1893,  an  excellent  argument  for  the 
thorough  irrigation  of  the  colon  in  typhoid  fever.  These  injections,  to 
effect  the  most  good,  should  be  employed  early  in  the  disease,  before 
the  high  fever  and  severe  nervous  symptoms  show  themselves.  They 
may  be  repeated,  if  necessary,  at  intervals  of  three  days  for  the  first 
week  or  ten  days.  They  should  be  used  warily  when  the  stage  of 
necrosis  of  the  glandular  tissue  is  reached,  as  the  solitary  glands  of  the 
large  intestine  are  affected  in  a  large  proportion  of  cases. 

Having  treated  several  cases  of  typhoid  fever  during  the  summer 
and  autumn  of  1892,  Dr.  Schuell  observed  that  by  thorough  irrigation 
of  the  colon  at  an  early  date  cases  were  rendered  comparatively  light. 
While  they  were  not  materially  shortened  in  duration,  they  lost 
the  typical  typhoid  picture,  the  lassitude,  subsultus  tendinum,  deli- 
rium, dry  and  fissured  tongue;  and  convalescence  was  uninterrupted 
and  rapid.  The  contrast  between  the  ordinary  so-called  disinfectant 
method  and  this  method  of  disinfection,  which  is  certainly  more 
rational  than  sending  feeble  medicinal  antiseptics  into  the  long  intes- 
tinal canal  on  the  same  mission,  offers  a  striking  clinical  lesson. 

Confirmation  of  the  value  of  irrigation  treatment  of  typhoid  fever 
is  furnished  by  the  article  of  Dr.  Hensel-Meseritz,  *  who  maintains  that 
a  careful  cleansing  of  the  intestinal  canal  may  be  very  useful,  not  only 
in  cases  of  marked  constipation  but  also  in  plainly  marked  cases  of 
typhoid  fever,  when  we  have  temperature  of  over  40°  C.,  characteristic 
diarrhceal  stools,  lung  symptoms,  and  enlargement  of  the  spleen. 

In  this  way  baths  were  avoided  and  compresses  may  be  reserved  for 
special  cases.  The  entire  nursing  of  tj'phoid  cases  was  much  simpli- 
fied and  the  results  were  surprisingly  good. 

Dysentery. — This  very  common  disease  of  infants  and  adults  is 
usually  amenable  to  ordinary  treatment.  In  cases  resisting  the  latter, 
irrigation  with  one  or  two  quarts  of  water,  about  95°  to  100°  F.,  made 
thoroughly  aseptic  by  long  boiling  and  rendered  unirritating  by  the 
addition  of  half  a  teaspoonful  of  salt  to  each  quart,  has  proved  a  valu- 
able auxiliary  by  removing  pathological  products,  subduing  hyperaemia, 
relieving  tenesmus  more  efficiently  than  anodyne  enemata,  and  thus 
enabling  the  inflamed  bowel  to  obtain  that  rest  which  in  all  inflamma- 
tory affections  is  the  chief  element  of  restoration.  All  these  effects 
are  due  to  the  mechanical  cleansing  action  of  water.  They  demand 
careful  attention  to  the  details  of  the  procedure,  to  inculcate  which 
*Allgemeine  Medizinal-Zeitung,  1896. 


292        THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

experience  has  taught  me  to  be  necessary.  While  it  is  important  in 
acute  cases  to  introduce  the  tube  high  into  the  colon,  it  is  not  neces- 
sary in  subacute  cases  to  introduce  the  tube  beyond  four  or  five  inches 
from  the  anus.  It  should,  however,  fairly  enter  the  ascending  colon, 
in  order  to  avoid  distention  of  the  rectum  and  irritation  of  the  lower 
colon.  It  is  needless  to  add  that  a  diet  restricted  to  gruels,  etc.,  is 
of  paramount  importance.  In  the  author's  somewhat  extensive  obser- 
vations, medication  after  the  first  purgative  is  futile,  if  not  positively 
harmful,  with  the  exception  of  large  doses  (40  to  60  gr.)  bismuth 
subnit.  every  three  or  four  hours  to  protect  the  inflamed  or  ulcerated 
mucous  surfaces. 

Dr.  Oliver  L.  Austin  *  deduces  from  the  recorded  observation  of 
234  cases  that  "  intestinal  irrigation  carefully  and  persistently  carried 
out,  after  personal  instruction  of  the  nurse,  kept  the  bowels  free  from 
irritating  accumulations,  prevented  the  growth  of  the  Shiga  bacillus 
and  its  toxins,  lessened  the  number  of  stools,  relieved  pain  and  tenes- 
mus,  and  controlled  toxaemia."  The  irrigations  failed  to  abort  the 
cases,  as  did  other  treatment,  but  proved  to  be  "the  measure  which 
had  the  greatest  curative  effect  in  protracted  cases." 

Dr.  Patterson,  of  Edgefield,  S.  C.,  made  the  ingenious  suggestion 
in  1896  to  stretch  the  sphincter  under  ether  before  irrigating;  he  has 
succeeded  in  cases  which  resisted  other  treatment. 

Confirmatory  evidence  of  the  value  of  this  simple  hydriatric 
measure  is  furnished  by  a  report  on  the  subject  in  The  Medical  Age, 
August  25th,  1891.  Dr.  Peter  S.  Korytin  (Russia)  details  15  succes- 
sive cases  of  diphtheritic  (9)  and  catarrhal  (6)  dysentery  which  he 
treated  daily  with  large  warm  (30°  R.  or  100°  F.)  euemata  of  six 
pints  either  of  filtered  water  from  the  tap  or  of  a  carbolic  solution, 
from  ten  to  twenty  grains  in  six  pints  of  distilled  water,  which  is  prac- 
tically equivalent  to  plain  water.  Only  one  of  the  patients  died,  the 
remaining  fourteen  making  excellent  recoveries.  The  total  number  of 
the  injections  in  individual  cases  varied  from  one  to  six.  The  injected 
fluid  was  retained  by  the  patient  generally  from  five  to  ten  minutes, 
being  sometimes  expelled  in  one  or  two,  and  in  other  cases  in  from  fif- 
teen to  twenty  minutes.  The  following  effects  were  commonly  ob- 
served :  Abnormal  distention  and  pain  speedily  subsided ;  the  frequency 
of  stools  diminished  and  tenesmus  decreased;  the  spirits,  appetite,  and 
sleep  quickly  improved;  the  stools  soon  became  painless,  more  solid, 
and  free  from  offensive  odor,  mucus,  blood,  sloughs,  and  shreds,  while 
the  temperature  became  normal.  No  therapeutic  difference  whatever 
was  noticed  between  carbolic  and  simple  enemata.  It  appears,  there- 

*  Medical  Record,  August  9th,  1904. 


IRRIGATION.  293 

fore,  that  the  beneficial  results  of  the  treatment  should  be  attributed 
simply  to  the  thorough  washing  out  of  the  large  intestine. 

This  statement  is  confirmed  by  Tuttle,  who  in  an  exhaustive  essay 
on  amoebic  dysentery  *  writes :  "  The  whole  treatment  should  be  di- 
rected toward  the  local  lesions,  the  destruction  of  the  amoebae,  and  the 
prevention  of  their  development  from  spores ;  and  as  these  are  buried 
in  the  tissues,  it  is  evident  that  it  will  be  impossible  to  destroy  them 
by  superficial  washing  or  flushing  of  the  intestinal  canal,  although  this 
treatment  is  important  to  get  rid  of  all  the  germs  floating  in  the  colon. 
It  is  clear,  however,  that  something  should  be  employed  by  which  the 
tissues  may  be  penetrated  and  the  germs  or  spores  destroyed  in  order 
to  completely  eradicate  the  disease.  While  the  remedies  mentioned — 
bichloride  of  mercury,  nitrate  of  silver,  saline  solution,  solutions  of 
quinine,  peroxide  of  hydrogen,  etc. — may  be  germicidal  to  the  amoeba 
when  brought  in  direct  contact  with  it,  it  is  perfectly  clear  that  none 
of  these  remedies  will  penetrate  the  submucosa. 

' '  This  fact  explains  why  so  many  cases  treated  by  these  remedies 
recur.  The  ideal  treatment  must,  therefore,  consist  of  some  method 
by  which  these  buried  organisms  can  be  reached  and  destroyed  in  situ. 
Early  in  our  studies  of  Amceba  dysenteries  it  was  discovered  that  when 
the  specimen  stools  on  the  slides  on  which  they  were  being  examined 
cooled  off  below  a  temperature  of  about  70°  F.,  the  motility  of  the 
amoebae  was  lost  and  could  not  be  restored  ;  this  fact  suggested  that 
if  the  temperature  of  the  parts  containing  these  organisms  could  be 
reduced  considerably  below  this  degree,  the  amoebae  could  be  destroyed 
and  their  infecting  and  reproductive  powers  would  be  eliminated. 
The  application  of  cold  to  the  intestinal  mucous  membrane  through 
prolonged  douches  seemed  to  offer  a  solution  of  the  question.  At  first 
such  remedies  as  krameria,  ichthyol,  bichloride  of  mercury,  and  nitrate 
of  silver  were  introduced  into  the  cold  douches,  but  one  after  another 
was  discarded,  as  it  was  found  that  simple  cold  water  served  every  pur- 
pose in  destroying  the  amcebce." 

The  practical  nature  of  this  author's  essay  is  evidenced  by  his  rec- 
ommendation to  use  a  glass  reservoir  in  preference  to  the  fountain 
syringe,  because  the  former  may  be  filled  with  cracked  ice  and  kept 
very  cold.  He  claims  that  the  best  results  were  obtained  by  irriga- 
tions with  water  below  45°  F.  He  correctly  advises  to  adopt  the  pa- 
tient's tolerance  as  to  quantity  and  temperature  as  a  guide,  beginning 
with  a  small  quantity  and  increasing  to  several  quarts.  Out  of  73 
cases  70  were  cured,  one  died,  one  had  liver  abscess  before  recovering, 
and  one  "went  to  Europe  improved. 

*  Jour.  Amer.  Med.  Assn.,  October  8th,  1904. 


294        THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

Dr.  Fenton  Turck  uses  water  105°  to  122°  F.  in  dyseutery,  allows 
this  to  flow  in  and  out,  and  this  is  followed  by  ice  water. 

Intestinal  Obstruction. — Colono-enteric  irrigation  has  been  found 
useful  in  the  treatment  of  intestinal  obstruction.  Dr.  Edwin  Pynchen* 
reports  a  case  of  intestinal  obstruction  successfully  treated  by  con- 
tinued irrigation  in  a  girl  aged  fourteen,  who  had  not  had  an  alvine 
evacuation  for  three  days,  and  had  been  eating  chiefly  cheese,  crackers, 
oranges,  and  grapes,  swallowing  the  seeds  of  the  grapes,  and  also 
chewing  gum. 

"  The  patient  was  anaesthetized  arid  suspended  head  downward  over 
a  chair  which  had  been  inverted,  the  back  of  the  chair  resting  upon 
the  floor  and  the  seat  being  supported  by  a  stool.  A  fountain  syringe, 
for  the  continuous  pressure  afforded,  was  filled  with  water  at  a  tem- 
perature of  110°  F.  and  raised  to  the  ceiling.  A  fall  of  as  much  as 
thirty  feet  for  an  adult  and  fifteen  for  a  child  is  better  still,  as  indi- 
cated by  the  experiments  of  W.  E.  Forrest,  who  found  that  the  intes- 
tines of  an  adult  would  stand  a  pressure  of  fifteen  pounds  to  the  square 
inch,  while  in  the  case  of  a  small  child  the  maximum  was  about  nine 
pounds,  the  pressure  obtained  from  a  column  of  water  being  one  pound 
to  each  two  and  a  half  feet.  In  the  author's  case  the  effect  of  the 
water  was  augmented  by  forcible  abdominal  massage,  and  two  and  a 
half  gallons  were  thus  driven  into  the  intestine.  When  this  amount 
had  been  reached,  there  was  a  violent  gushing  of  water  from  the  pa- 
tient's mouth,  about  a  gallon  escaping  in  this  way.  The  procedure 
was  then  stopped,  and  when  the  patient  was  sufficiently  recovered  from 
the  anaesthetic  to  be  placed  on  a  slop-jar  another  gallon  escaped  per 
rectum.  The  child  recovered  without  further  trouble  and  had  a  nor- 
mal stool  on  the  second  day." 

I  have  treated  a  child  of  four  years  who  had  been  unconscious  for 
twenty-four  hours,  and  suffering  from  eclamptic  attacks  every  ten  or 
fifteen  minutes;  the  stomach  was  irrigated  and  a  large  dose  of  castor 
oil  administered  through  a  tube  passed  into  the  oesophagus  through 
the  nose.  The  castor  oil  was  returned  together  with  a  large  quantity 
of  bile  when  the  tube  was  rein  trod  uced  six  hours  later.  Intestinal  ob- 
struction, which  was  diagnosed  and  concurred  in  by  Dr.  A.  Jacobi  and 
Dr.  Charles  Kinch,  was  removed  by  a  large  rectal  irrigation  adminis- 
tered in  the  inverted  position.  The  convulsions  ceased  after  a  free 
evacuation  and  the  child  became  conscious. 

Pernicious  Anaemia. — In  a  carefully  prepared  paper  on  toxic  origin 
of  pernicious  anaemia  by  Hollis  and  Ditmar  f  the  haemolytic  action  of 
the  Bacillus  aerogenes  capsulatus  (Welch)  is  clearly  brought  out. 

*  Chicago  Medical  Recorder,  1896. 
f  Medical  Record,  February  2d,  1907. 


IRRIGATION.  295 

Herter  had  shown  that  the  bacterium  is  abundant  in  the  colon  in  cases 
of  anaemia,  and  that  it  is  able  to  break  down  proteids  into  forms  suita- 
ble for  the  sustenance  of  other  putrefactive  bacteria,  which  form  iudol, 
a  substance  quite  often  present  in  intestinal  putrefaction.  On  the 
suggestion  of  Herter  two  cases  of  undoubted  pernicious  anaemia  were 
treated  by  colon  irrigation  in  hospital.  By  colon  irrigation  in  these 
cases  more  marked  improvement  was  obtained  than  by  any  other 
method  employed.  It  is  also  evident  that  the  fact  that  two  very 
severe  cases  of  anaemia  of  the  pernicious  type  have  been  restored  to 
perfect  health  and  a  normal  blood  condition  by  high  colon  irrigations 
would  seem  to  imply,  for  these  cases  at  least,  the  absorption  of  some 
toxic  substance  from  the  bowel  as  a  causative  agent. 

The  great  value  in  the  discovery  that  such  a  condition  as  pernicious 
anaemia  can  be  so  benefited  by  removing  intestinal  bacterial  matter  lies 
in  the  fact  that  it  emphasizes  the  possibility  of  attacking  other  obscure 
diseases  on  the  same  ground.  The  agency  of  bacteria  in  disease  seems 
to  be  well  appreciated  when  they  occur  in  contact  with  the  surface  of 
the  body,  in  the  oral  or  genito-urinary  or  respiratory  cavities.  Even 
the  deleterious  effect  of  the  absorption  of  the  products  of  the  activity 
of  non-pathogenic  or  saprophytic  bacteria  is  known,  when  occur- 
ring within  the  uterus,  to  produce  a  sapremia.  Yet  few  seem  to  ap- 
preciate what  a  great  amount  of  absorption  must  occur  where  the  area 
of  absorption  is  as  great  as  that  of  the  intestinal  mucosa,  or  what  a 
diversity  of  chemical  products,  many  the  result  of  bacterial  activity, 
present  themselves  for  absorption.  It  is,  however,  of  extreme  impor- 
tance to  recognize  this  diversity  of  chemical  products,  many  of  which 
in  conditions  of  health  may  not  be  toxic,  but  under  conditions  of  slight 
impairment  of  the  detoxicating  or  oxidizing  action  of  the  liver  or  in- 
testinal mucosa,  or  when  acting  through  long  periods  of  time,  may  be 
responsible  for  many  of  our  unsolved  symptom  complexes  of  disease. 

Lead  Colic. — There  is  no  disease  which  embarrasses  the  physician 
more  than  lead  colic.  Frequently  obscure  in  origin,  our  remedial  agents 
do  not  reach  the  cause.  Many  medicinal  agents  have  been  vaunted, 
but  their  inefficiency  has  led  us  to  reach  out  for  additional  therapeutic 
aid.  That  hydrotherapy  holds  out  some  promise  is  evident  from  the 
case  of  Reisland,  published  in  the  Berliner  klinische  Wochenschrift,  1875. 
The  patient  had  been  constipated  five  days,  despite  the  most  active  pur- 
gation; he  was  collapsed,  with  frequent  spasms  of  the  arms  and  legs  and 
vomiting  of  bile;  the  face  was  pale  and  ashen.  The  teeth  presented  a 
plain  lead  line;  abdomen,  hard  and  retracted;  pulse,  small  (65);  tem- 
perature, normal.  Croton  oil  and  opiates  were  ineffectual,  also  ene- 
mata.  Four  and  a  half  litres  of  warm  water  were  now  poured  into  the 
bowel  with  a  Hegar's  irri gator.  The  water  returned  in  five  minutes, 


296        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

colored  by  faeces  and  containing  some  scybala.  The  patient  obtained 
so  much  relief  that  he  insisted  upon  a  repetition.  Three  litres  were 
introduced,  and  were  followed  in  half  an  hour  by  the  same  quantity, 
each  injection  being  followed  by  faeces  and  relief  from  pain.  The 
knee-elbow  position  was  practised  during  irrigation.  The  patient 
became  more  nauseated,  but  after  the  third  irrigation  he  slept  well  for 
the  first  time  in  six  days.  The  pain  returned,  and  three  more  injec- 
tions of  three  and  two  and  one-half  litres  brought  stools  and  relief. 
On  the  following  day  the  pain  and  spasms  returned,  and  were  again 
relieved  by  irrigation.  The  patient  received  one  more  irrigation  of 
three  litres,  which  brought  a  good  faecal  evacuation,  and  he  was  assisted 
to  entire  recovery  by  a  dose  of  ol.  ricini  and  ol.  crotoni  and  a  warm  bath. 
In  Kussmaul'  s  clinic  at  Freiburg  this  treatment  has  been  used  for  many 
years.  Whether  lead  colic  be  a  neurosis  of  the  intestinal  muscular 
coat,  or,  as  Kiegel  deduced  from  the  effect  of  amyl  and  pilocarpine,  a 
spasm  of  the  mesenteric  vessels,  it  is  certain  that  abundant  warm  injec- 
tions per  anum  may  avert  colic  in  its  incipiency  and  act  as  a  good  pallia- 
tive. It  is  very  interesting  to  note  that  this  procedure  quickly  pro- 
duces faecal  evacuations,  irrespective  of  the  rejected  enemata,  proving 
that  they  induce  a  normal  activity  of  the  intestine. 

In  toxcemic  conditions  a  unique  method  of  irrigating  the  intestinal 
canal  for  the  purpose  of  washing  out  impurities  is  advised  by  Wernitz,* 
which,  having  the  merit  of  innocuousness  and  thoroughness,  deserves 
imitation.  A  one-per-cent  salt  solution  of  neutral  temperature  is  al- 
lowed to  flow  into  the  rectum.  When  the  desire  for  expulsion  begins, 
the  reservoir  is  lowered  so  that  the  faecal  matter  held  in  solution  enters 
it.  This  is  emptied  and  refilled  from  a  previously  prepared  sup- 
ply. Under  slight  pressure  this  in-  and  out-flow  is  repeated  until  the 
water  returns  clear.  Cramps  are  a  signal  for  lowering  the  reservoir. 
About  a  quart  of  water  may  thus  be  absorbed  in  the  course  of  an  hour. 
The  irrigation  is  repeated  every  two  hours,  unless  greatly  distressing. 
The  chief  aim  is  to  produce  absorption  of  water  from  the  intestinal 
mucosa.  The  effect  is  an  enormous  increase  of  urine,  disappearance 
of  thirst,  moistening  of  the  parched  mucous  membranes,  diaphoresis, 
and  subsidence  of  temperature  after  each  irrigation. 

Acute  prostatitis  is  successfully  managed  by  hot  irrigations  of  the 
rectum,  according  to  Desnos.*  Pain  is  diminished  and  often  the  dis- 
ease is  aborted.  Desnos  recommends  enteroclysis  of  water  at  50°  C. 
(122°  F.),  admitted  slowly  at  first  through  a  short  tube  and  played 
guttatim  upon  the  swollen  prostate,  gradually  increasing  the  quantity 
(the  author  suggests  beginning  with  a  temperature  of  100°  F.,  full 
stream  and  low  pressure,  gradually  increased  to  a  point  of  tolerance). 
*  Wiener  med.  Presse,  1903. 


IRRIGATION. 


297 


Desnos  applies   these  hot  irrigations  twice  daily,  if  well  borne,  for 
twelve  to  fifteen  minutes. 

The  treatment  is  injurious  in  chronic  prostatitis. 


IRRIGATION  OF  THE  MALE  URINARY  TRACT. 

Irrigation  of  the  bladder  has  long  been  in  vogue  as  a  remedial  or 
palliative  agent  in  bladder  diseases.  This  is  usually  done  by  a  double- 
current  catheter  attached  to  a 
fountain  syringe. 

An  improved  device  is  de- 
scribed by  Dr.  E.  L.  Keyes,  an 
eminent  authority  on  this  sub- 
ject. Dr.  Keyes  justly  claims 
that  to  wash  out  the  bladder 
thoroughly  it  must  be  some- 
what distended. 

Technique. — The  fluid  to  be 
injected    is   eight 
ounces  or  more,  at  a 
temperature  of, 
about  110°  F.    Some 
of  the  heat   is  lost 
during  the  prepara- 
tion.     Standing   in 
front  of  a  stool  bear- 
ing some  receptacle, 
the    patient   slowly 
introduces  his  catheter,  dipped  in  vaseline,  and  already  attached  to  the 
large  metallic  mouthpiece. 

As  soon  as  the  urine  begins  to  flow,  he  immediately  couples  the 
large  nozzle  of  the  stopcock  and  the  large  metallic  mouthpiece  with 
which  his  catheter  has  been  provided,  and  the  urine  flows  promptly 
through  the  short  rubber  tube  into  the  vase  on  the  stool  before  him. 
When  the  urine  has  escaped,  he  turns  the  stopcock  and  the  bladder 
slowly  fills  with  water.  As  soon  as  the  organ  begins  to  feel  distended, 
he  turns  the  stopcock  again,  so  slowly  and  quietly  that  he  scarcely  per- 
ceives the  motion. 

He  may  thus  wash  his  bladder  very  thoroughly  four,  five,  or  six 
times  without  any  change  of  the  instrument  or  its  adjustment,  except 
the  simple  turning  to  and  fro  of  a  stopcock ;  and  this  he  does  until  the 
water  flows  comparatively  clear  from  his  bladder. 


FIG.  58.— Keyes'  Bladder  Irrigator. 


298        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 


For  irrigation  of  the  urethra  a  useful  instrument  is  that  devised  by 
Dr.  Lester  Keller.  It  is  made  of  sterling  silver,  not  readily  corroded, 
and  easily  kept  bright.  It  is  made  in  two  lengths — one  for  the  curved 
and  one  for  the  straight  portion  of  the  urethra. 

A  tube  is  corrugated  to  permit  the  liquid  to  flow  back,  and,  by 
occasionally  rotating  the  tube  very  slightly,  every  portion  of  the 
mucous  membrane  is  reached.  The  openings  for  the  outflow  of  liquid 
are  behind  the  bulb,  so  the  liquid  cannot  enter  the  bladder. 

Technique. — The  instrument  is  introduced  until  the  "tender  spot" 
is  passed,  and  we  generally  find  one ;  then  the  tube  of  an  ordinary 
fountain  syringe  is  attached,  and  by  the  raising  or  lowering  of  this  the 
pressure  is  easily  governed. 

About  a  quart  of  water  may  be  used,  which  may  be  repeated  at 
each  sitting,  about  twice  a  week.  Usually  two  or  three  sittings  suffice. 

IRRIGATION  OF  THE  URETHRA  AND  BLADDER  WITHOUT  THE 

CATHETER. 

Dr.  Daggett,  of  Buffalo,  has  introduced  a  method  of  irrigation 
which  presents  decided  advantages  over  all  others,  in  that  it  does  not 
require  the  introduction  of  a  catheter  into  the  urethra, 
which  is  usually  exceedingly  tender  in  its  posterior  por- 
tion in  cases  of  chronic  gonorrhoea.  "  The  apparatus 
consists  of  a  short  stem,  which  gradually  decreases  in 
size  in  such  manner  that  its  introduction  into  the  ure- 
thra closes  the  latter  by  its  wedge  shape.  This  is  con- 
nected with  an  inflow  and  outflow  tube,  as  shown  in 
Fig.  59. 

"  Technique. — The  materials  are  a  four-quart  bag 
and  a  tube  six  feet  long  with  a  shut-off  within  easy  reach. 
The  tube  is  attached  to  the  inlet  of  this  double  cannula, 
its  bore  being  twenty  per  cent  larger  than  that  of  the 
outlet.  The  nozzle  of  the  cannula  is  introduced  from 
one  inch  to  two  inches,  according  to  the  size  of  the 
meatus,  and  is  made  wedge  shaped,  in  order  to  fill  the 
varying  calibres  of  urethral  meatus.  It  is  sufficiently  long  to  be  con- 
veniently held  in  place  by  grasping  the  penis  behind  the  glans,  at  the 
same  time  drawing  the  pendulous  portion  in  line  with  the  fixed  urethra. 
The  bag  is  filled  with  water,  at  a  temperature  of  115°,  to  insure  more 
than  blood  warmth  as  it  flows,  and  is  made  bland  by  the  addition  of  a 
little  glycerin,  mucilage,  a  few  grains  of  salt  or  sodium  carbonate,  and 
elevated  two  or  three  feet  above  the  plane  of  the  pelvis. 

"  The  patient  must  assume  a  reclining  position — a  reversed  squat  - 


FIQ.   59. 


IRRIGATION.  299 

ting  posture — since    flexure    and  gravity   are   essential   factors  (Fig. 
CO). 

"  He  may  do  this  in  an  ordinary  bathtub  by  resting  his  back  along 
the  incline  at  its  head,  so  that  the  trunk  is  at  an  angle  of  forty -five 
degrees  from  the  horizontal  line,  flexing  the  thighs  at  right  angles  with 
the  body  and  supporting  the  legs  at  right  angles  with  the  thighs.  If 
there  is  no  bathtub  at  hand,  a  hip  bath  may  be  arranged  for  this  pur- 


Fio.  60. 

pose,  or  the  patient  may  posture  himself  in  a  low  rocking  chair,  tilted 
and  blocked  (Fig.  60)  so  that  his  body  assumes  the  position  described, 
his  legs  resting  upon  another  chair  or  upon  a  stand. 

"  The  nozzle  of  the  irrigator  is  then  introduced,  the  penis  grasped  and 
drawn  in  line  with  the  fixed  urethra,  the  stop  opened,  and  the  water  al- 
lowed to  run,  if  necessary  until  the  bag  is  empty ;  if  it  has  not  passed 
into  the  bladder,  try  again.  A  peculiar  feeling  gives  warning  of  the 
passing  of  the  water  through  the  posterior  urethra;  the  return  flow 
diminishes  and  escapes  in  a  pulsating  stream,  when  a  finger  of  the 
right  hand  is  placed  over  the  exit  to  divert  the  entire  flow  into  the 
bladder,  which  at  first  resents  the  intrusion  and  ejects  the  water  after 
receiving  two  or  three  ounces.  Kepeat  this  and  the  bladder  becomes 
more  tolerant  each  time.  Three  or  four  flushings  are  sufficient  at  each 
seance,  and  the  seances  may  be  repeated  three  times  daily  if  necessary. 
The  novelty  and  comfort  afforded  by  irrigation  sometimes  induce 
patients  to  overdo,  at  the  beginning,  before  tolerance  is  established. 


300        THE   PRINCIPLES   AND    PRACTICE   OF   HYDROTHERAPY. 

The  diminished,  pulsating  outflow  would  seem  to  indicate  an  anti-  or 
retro-peristaltic  action  of  the  accelerator  muscle.  This  process  is  a 
coaxing  one,  in  which  the  gentle  pressure  of  the  continuous  flow  of  the 
hot,  non-irritating  current  and  the  posture  described  are  essential  con- 
ditions. The  patient  acquires  a  knack  at  the  first  success  that  gives 
him  an  abiding  faith  in  his  ability  to  flush  his  bladder  at  will." 

Therapeutics. — The  management  of  urethral  diseases  has  long  been 
a  reproach  to  the  profession.  The  fact  that  numberless  and  diverse 
formulae  for  use  in  this  malady  burden  our  text-books  and  encumber  our 
journals  indicates  that  the  profession  is  at  sea,  that  our  methods  are 
uncertain,  and  our  treatment  is  empirical.  "A  steady  in-  and  out- 
flowing current  of  hot  water,  with  the  patient  in  this  position,  is  a  far 
more  valuable  measure  in  the  treatment  of  stubborn  cases  of  urethritis 
than  the  ordinary  deep  injection,  which  may  be  compared  to  treating 
laryngitis  by  rinsing  the  mouth." 

Mechanical  cleansing  is  now  acknowledged  as  far  superior  to  the 
best  chemical  agents,  for  purposes  of  asepsis  and  antisepsis.  Just  as 
in  peri-uterine  congestions  and  inflammatory  conditions  the  steady  irri- 
gation with  hot  water  constringes  the  vessels  and  aids  absorption  of 
pathological  products,  so  must  a  continuous  irrigation  of  the  bladder 
and  urethra,  properly  administered,  produce  a  similar  detergent  effect 
upon  parts  which  a  brief  injection  with  some  strong  medicament  fails 
to  affect.  When  we  consider,  for  instance,  the  measure  recommended 
by  Guyon  and  others  for  treating  chronic  cystitis,  viz.,  the  injection 
guttatim  of  a  strong  solution  of  nitrate  of  silver,  which  is  expected  to 
be  more  or  less  diluted  by  the  urine  present  in  the  bladder,  we  must 
grant  that  this  is  an  exceedingly  irrational  procedure  when  compared 
with  the  thorough  cleansing  of  the  inflamed  surface  by  hot  water. 

Dr.  Daggett  cites  a  number  of  cases,  which  convey  a  correct  idea  of 
the  value  of  this  modern  treatment  and  are  well  worth  studying,  and 
of  which  the  following  is  an  example : 

CASE  I. — R ,  63  years  of  age,  twenty-three  years  ago  had  a  very  severe 

attack  of  cystitis ;  ill  several  months,  and  never  fully  recovered.  He  had  been 
confined  to  his  room  four  weeks ;  irrigation  by  double  catheter  was  employed  ; 
his  condition  grew  steadily  worse.  His  attending  physician  proposed  cystotomy. 
He  presented  all  the  phenomena  of  septic  infection.  His  urine  was  strongly 
alkaline,  offensive,  depositing  one-quarter  part  by  volume  of  solid  matter,  con- 
sisting of  pus  and  inflammatory  debris.  R readily  learned  self-irrigation 

without  the  catheter,  and  cleared  his  urine  in  five  days  and  was  able  to  attend  his 
office.  There  still  remained  a  tendency  to  relapse,  -which  was  controlled  by  irri- 
gation. He  is  now  able  to  evacuate  the  bladder  completely  by  a  good  stream. 

Chronic  Prostatic  Hypertrophy. — About  thirty-three  and  one-third 
per  cent  of  men  between  the  ages  of  fifty-five  and  sixty  have  more  or 


IRRIGATION.  301 

less  enlargement  of  the  prostate,  and  a  small  percentage  of  these  suffer 
from  urinary  obstruction  and  its  attendant  evils. 

Enlargement  of  the  prostate  may  impede,  but  will  not  prohibit  pass- 
ing a  fluid  into  the  bladder  by  this  process.  Passing  water  into  the 
bladder  in  cases  in  which  the  patient  was  unable  to  void  it  without  a 
catheter  is  made  possible  by  this  method. 

An  interesting  phenomenon,  developed  by  this  process,  is  the 
restoration  of  impaired  procreative  functions. 

After  several  years'  experience  and  two  score  cases  as  they  occur 
in  the  rounds  of  a  general  practice,  Dr.  Daggett  feels  warranted  in  as- 
serting that  more  than  ninety  per  cent  of  these  patients  may  be  taught 
to  irrigate  the  bladder  without  a  catheter. 

"  Success  is  attained  by  technique,  posture,  and  perseverance, "  in 
these  cases  as  in  others  in  which  hydrotherapy  is  judiciously  applied. 

The  common  error,  that  hydrotherapy  deals  with  cold  water  exter- 
nally applied  only,  is  exposed  by  these  effective  remedial  applications 
of  ordinary  warm  water. 

VAGINAL  IRRIGATION. 

In  the  treatment  of  utero-ovarian  diseases,  vaginal  irrigations  have 
come  to  be  a  routine  treatment,  which  is  of  value  just  in  accordance 
with  the  proper  execution  of  the  details  of  the  procedure. 

Technique. — The  chief  points  to  be  observed  in  the  preparation  of 
vaginal  irrigations  are  that  the 
following  be  provided:  (1)  a 
douche  pan  (zinc  or  porcelain) ; 
(2)  a  fountain  syringe  holding 
two  or  more  quarts  of  water  at 
110°  F. ;  (3)  a  proper  couch  or 
bed  upon  which  the  hips  may  be 
elevated.  The  fountain  syringe 
being  suspended  from  a  height  of  F*0-  61.— Douche  Pan. 

several  feet  and  the  douche  pan 

having  been  warmed,  the  latter  is  so  placed  under  the  patient  that  her 
nates  rest  on  the  covered  portion.  A  vaginal  tube  having  openings 
which  direct  the  outflowing  stream  forward,  to  prevent  the  latter  enter- 
ing the  uterine  canal,  is  attached  to  the  rubber  tube  leading  from  the 
syringe  and  introduced  as  far  into  the  posterior  cul-de-sac  as  possible 
without  causing  pain  or  discomfort.  The  clamp  which  prevents  the 
outflow  is  now  opened,  and  the  water  is  allowed  to  flow  in  a  continuous 
stream  through  the  vagina  into  the  pan. 


302        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

Dr.  X.  Bozeinan  *  has  devised  a  vaginal  irrigator  which  delivers 
water  mixed  with  air.  He  claims  that  the  main  feature  is  the  intro- 
duction of  sterilized  air  with  the  hot  water  into  the  vagina  and  the  with- 
drawal of  the  same  by  slight  suction  before  it  can  accumulate  there  in 

sufficient  quantities  to  flow 
over  the  perineum  and  wet  the 
patient' s  clothing  and  the  bed- 
ding. 

He  has  recently  simplified 
this  apparatusf  by  substitut- 
ing a  rubber  bag  for  the  glass 
reservoir. 

Dr.  Robert  C.  Kemp  J  has 
devised  an  ingenious  double- 
current  irrigator  (Fig.  62)  for 
the  vagina,  which  serves  with- 
out a  douche  pan. 

This  appliance  is  also  made 
of  glass. 

All  vaginal  irrigations 
should  be  administered  with 

FIG.  62.— Kemp's  Vaginal  Irrigator.  . 

the  patient  lying  recumbent; 

the  upright  position  on  a  bidet  or  closet  being  imperfect,  because  the 
vagina  is  not  distended  by  the  stream.  For  cleansing-purposes  the 
temperature  of  the  water  should  not  be  above  100° ;  for  astringent  or 
antiphlogistic  purposes  the  temperature  should  be  100°-120°,  begin- 
ning with  100  and  gradually  increased  by  adding  hot  water,  until  the 
patient  complains  of  the  heat.  In  these  cases  the  hips  should  be  ele- 
vated and  the  quantity  of  water  should  be  large,  three  or  four  quarts. 
The  perineum  should  be  anointed  and  care  should  be  taken  to  avoid 
metal  tubes  and  to  protect  against  painful  heating  of  the  parts. 

The  procedure  cannot  be  executed  with  precision  without  assist- 
ance. Here,  as  in  other  hydriatric  procedures,  the  best  results  may  be 
obtained  only  from  the  best  technique.  Unfortunately  the  latter  is 
possible  only  in  hospitals  and  in  cases  of  women  able  to  obtain  assist- 
ance for  each  injection.  The  usual  method  of  self -irrigation  is  faulty 
but  must  in  the  larger  proportion  of  cases  suffice. 

Rationale. — Tepid  water  relaxes  the  vagina  and  facilitates  cleans- 
ing in  ordinary  leucorrhcea.  Hot  water  (not  less  than  110°  F.)  on 
the  other  hand  corrugates  the  mucous  membrane,  drives  the  blood 
out  of  the  pelvic  veins,  as  is  evident  by  the  blanched  appearance 

*New  York  Medical  Journal,  May  27th,  1893. 

\lbid.,  September  29th,  1894.  \lbid.,  March  28th,  1896. 


IRRIGATION.  303 

of  the  mucous  membrane,  relieving  congestion.  The  repetition  of  the 
irrigation  thus  maintains  the  tone  of  the  pelvic  vessels,  and  by  stimu- 
lating absorption  and  removing  exudation  furthers  recovery.  A  warn- 
ing against  the  abuse  of  these  very  hot  injections,  which  have  come 
into  universal  practice,  may  not  be  out  of  place.  The  frequent  repe- 
tition of  such  injections,  in  conditions  not  requiring  them,  must  ex- 
haust the  contractile  capacity  of  the  vessels,  remove  the  natural  secre- 
tions of  the  vagirial  mucous  membrane,  and  maintain  an  introspection 
which  counteracts  the  natural  tendency  to  recovery.  Many  women, 
married  and  unfortunately  unmarried  also,  have  either  been  ad  vised  to 
take  these  injections  without  due  consideration  of  the  therapeutic  ob- 
jects in  view,  or  continue  them  as  a  routine  practice. 

Therapeutic  Indications. — The  chief  object  of  vaginal  irrigation  is, 
aside  from  cleansing,  the  treatment  of  inflammatory  conditions  in  the 
peri-uterine  and  vaginal  structures.  Surgery  has  very  materially 
limited  these  cases,  since  disease  of  the  Fallopian  tubes  has  been  dis- 
covered as  the  frequent  source  of  so-called  cellulitis  and  pelvic  peri- 
tonitis. There  are,  however,  many  cases  presenting  distressing  pelvic 
symptoms  amenable  to  this  simple  measure.  Indeed,  the  writer  has 
succeeded  in  restoring  some  women  to  health  after  himself  despairing 
of  them  without  surgical  interference.  There  is  no  doubt  that  the  lost 
tone  of  the  pelvic  vessels  may  be  restored  by  this  treatment  in  connec- 
tion with  other  measures — hip  baths,  glycerin  tampons,  and  general 
hygienic  improvement.  It  may  be  well  to  avoid  running  into  the 
opposite  extreme,  by  neglecting  these  valuable  measures  and  resorting 
to  surgical  mutilation,  which  is  unwarranted  until  all  other  means  have 
been  tried.  In  this  day  of  facile  unsexing  of  women  this  warning  is 
not  without  as  good  reason  as  is  the  opposite,  referred  to  above. 


CHAPTER  XII. 

METHODS  OF  COOLING  AND  HEATING  INTERNAL  PARTS. 

FOR  the  purpose  of  cooling  those  organs  and  parts  of  the  body 
which  are  accessible  to  cold,  water  may  be  conducted  through  rubber 
tubes  from  a  reservoir  to  an  instrument  which  lies  in  apposition  with 
the  part  to  be  treated. 

THE  PBOSTATIC  COOLER. 

This  apparatus  (psychrophore),  devised  by  Artzberger  for  rectal 
cooling,  consists  of  a  metallic  tube  closed  at  its  distal  end,  having  a 
flattened  portion  at  its  bulbous  portion,  which  fits  the  prostate  gland. 

Dr.  Alfred  Wiener  has 
modified  the  instrument, 
and  describes  it  (with  il- 
lustration)* as  follows: 

"  The  accompanying 
cut  is  a  very  good  repre- 
sentation of  the  instru- 
ment. It  is  similar  to 
Artzberger' s  cooling  ap- 
paratus, which  is  em- 
ployed abroad  in  the 
treatment  of  hemor- 
rhoids. The  close  prox- 
imity in  which  this  can 
be  applied  to  the  prostat- 
ic  portion  of  the  urethra 
FIG.  63.  lfid  me  to  make  use  of  it 

for  this  purpose. 

"  The  instrument  consists  of  a  simple  metallic  cold-water  coil,  con- 
structed in  the  shape  of  the  letter  T.  The  stem  of  the  instrument  (b) 
is  narrower  at  the  base  than  at  the  extremity,  and  is  about  one  and 
one-half  centimetres  in  thickness  at  its  widest  part,  and  one  centi- 
metre at  the  narrowest  portion.  It  is  bulbous  at  the  extremity  of 
the  stem,  and  contains  a  slight  concavity  just  below  the  head  of  the 
*  Medical  Record,  April  13th,  1895  (Fig.  7). 


METHODS   OF   COOLING   AND   HEATING   INTERNAL   PARTS.      305 

instrument.  Thus  it  easily  adapts  itself  to  the  rectum,  the  concavity 
fitting  itself  very  nicely  to  the  prostatic  portion  of  the  urethra.  The 
application  is  as  follows :  The  end  is  connected  with  a  rubber  bag  sus- 
pended immediately  above  the  patient,  who  is  most  conveniently  placed 
in  the  recumbent  position  with  his  back  to  the  operator.  A  piece  of 
tubing  long  enough  to  extend  from  the  couch  on  which  the  patient  is 
reclining  to  a  vessel  on  the  floor  is  attached  to  the  stem.  Now  fill  the 
bag  with  ice-water,  and  also  put  into  it  a  piece  of  ice  to  keep  the  water 
at  the  same  temperature.  The  instrument  is  then  introduced  into  the 
rectum,  well  oiled,  with  the  concavity  toward  the  scrotum.  The  water, 
which  had  previously  been  held  in  check  by  a  clamp  arrangement  on  the 
rubber  tubing,  is  now  allowed  to  flow  slowly  through  the  apparatus, 
and  into  the  pail  on  the  floor.  Instead  of  renewing  the  water  each 
time  it  flows  into  the  pail  on  the  floor,  it  may  be  poured  back  into  the 
rubber  bag.  The  application  should  last  about  ten  or  fifteen  minutes, 
and  should  be  repeated  daily.  The  patient  soon  becomes  accustomed 
to  the  use  of  the  instrument,  and  learns  very  rapidly  to  apply  it  alone." 

Therapeutic  Indications. — Sexual  neurasthenia  offers  the  chief  indi- 
cation for  the  use  of  the  prostatic  cooler.  According  to  Dr.  Wiener, 
whose  observations  I  have  had  abundant  opportunity  to  confirm,  before 
and  since  the  publication  of  his  paper,  patients  in  whom  the  prostatic 
portion  of  the  urethra  is  extremely  hyperaesthetic,  complain  of  fre- 
quent seminal  emissions,  with  more  or  less  exhaustion;  the  ejacula- 
tions are  premature,  and  the  erections  are  imperfect  and  of  short 
duration,  so  that  intromission  is  sometimes  impossible.  In  some  the 
sexual  desire  is  very  much  diminished,  in  others  it  is  absent.  In  con- 
nection with  these  local  symptoms  the  patient  complains  of  a  number 
of  neurasthenic  symptoms,  which,  together  with  the  former,  help  to 
make  him  a  confirmed  neurasthenic. 

Dr.  Wiener  cites  some  striking  clinical  histories  to  demonstrate  the 
value  of  this  simple  apparatus.  One  of  these  histories  may  be  briefly 
reproduced  as  an  illustration,  because  such  patients  are  the  bane  of 
the  physician's  life,  going  from  one  office  to  another  in  search  of  com- 
fort and  restoration. 

M.  J ,  aged  24 ;  married  several  years ;  was  at  one  time  addicted  to  mas- 
turbation. Three  and  a  half  years  after  marriage  he  noticed  that  although  he 
still  retained  sexual  desire  he  was  no  longer  able  to  control  his  erections  ;  he  was 
suffering  from  five  to  six  seminal  emissions  weekly,  which  exhausted  him  so  that 
he  was  hardly  able  to  attend  to  his  business  properly.  A  perfect  erection  was  an 
utter  impossibility.  This  condition,  together  with  a  slight  catarrhal  gastritis, 
combined  to  make  this  patient  very  miserable.  An  examination  of  the  penis  re- 
vealed a  state  of  affairs  that  one  most  frequently  finds  in  this  class  of  cases.  On 
passing  a  steel  sound,  No.  23  French,  a  simple  spasmodic  stricture  was  found. 
The  prostatic  portion  of  the  urethra  was  so  sensitive  that  the  patient  was  unable 
20 


306        THE   PRINCIPLES   AXD   PRACTICE   OF   HYDROTHERAPY. 


to  endure  the  pain.  Treatment  was  suspended  for  three  days,  when  a  psychro- 
phore  was  passed  alternately  every  third  day  during  the  first  week,  and  every 
day  during  the  second  and  third  weeks.  All  sexual  intercourse  was  interdicted  ; 
no  stimulating  drinks  were  allowed  ;  and  the  patient  was  put  upon  a  diet  con- 
sisting of  plain  and  easily  digested  food.  At  the  end  of  three  weeks  a  second 
examination  was  made,  and  the  result  was  so  discouraging  that  the  patient  would 
no  longer  submit  to  this  method  of  treatment.  The  sound,  psychrophore,  and 
potassium  bromide  were  replaced  by  cold  water  through  the  rectum  with  the 
prostatic  cooler.  The  result  was  astonishing.  At  the  end  of  the  first  week  im- 
provement had  already  set  in.  At  the  end  of  the  fourth  week  I  could  pass  a 
sound  without  any  difficulty.  The  emissions  had  ceased  entirely.  After  six 
weeks  of  treatment  the  patient  was  cured.  It  is  now  three  years,  and  he  has 
never  had  a  return  of  the  trouble  ;  the  genital  organs  are  in  perfect  condition. 

Twelve  such  histories  are  cited,  affording  an  ample  test  for  this 

treatment.  The  results  were  uniform- 
ly favorable  in  all  cases  which  had  been 
traced. 

I  have  not  been  so  uniformly  suc- 
cessful, often  finding  it  necessary  to 
resort  to  the  perineal  douche.  By  com- 
bining these  measures  I  have  restored 
several  unpromising  cases  of  this  type. 

THE  PERINEAL  DOUCHE 

(Fig.  64)  is  constructed  by  connect- 
ing the  hot  and  cold  water  supply 
with  an  upright  tube.  The  patient, 
seated  upon  a  box  or  stool  supplied 
with  an  opening  through  which  the 
perineum  is  exposed,  receives  the  as- 
cending stream  for  from  two  to  ten 
minutes  directly  upon  this  part. 

Therapeutic     Indications      of    the 
Perineal    Douche. — In     hemorrhoids, 
in    which  water  at  a  temperature   of 
60°-75°  is  projected  against  protrud- 
ing tumors,   for  antiphlogistic   or  astringent  purposes,  this  douche  is 
useful  if  repeated  several  times   daily  and  applied  with   moderate 
pressure. 

In  impotence  and  prostatic  hypertrophy  the  perineal  douche  is 
exceedingly  useful.  Several  cases  referred  to  me  by  genito-urinary 
specialists  and  treated  by  this  method  have  afforded  such  satisfactory 
results  that  I  would  commend  it  as  a  valuable  auxiliary  in  treating 
these  unhappy  individuals. 


FIG.  64.— Perineal  Douche. 


METHODS   OF   COOLING   AND   HEATING   INTERNAL   PARTS.      307 


THE  RECTAL  COOLER. 

The  cooling  bladder  of  Winternitz  consists  of  a  light  rubber  bag, 
secured  over  a  perforated  double-current  tube,  which  admits  of  the 
introduction  and  outflow  of  hot  or  cold  water.  The  entire  apparatus 
is  introduced  into  the  rectum,  the  patient  being  in  the  recumbent  pos- 
ture, and  the  water  is  made  to  flow  in  and  out  of  the  rubber  bladder, 
which  is  thus  distended.  It  has  been  applied  by  Winternitz  to  pain- 
ful hemorrhoids  chiefly. 

GOLDENBERG'S  COOLING  SOUND. 

Dr.  H.  Goldenberg  *  has  devised  an  instrument  for  the  treatment 
of  prostatitis. 

"  The  original  Arzberger's  hemorrhoidal  apparatus  has  proved  to  be 
a  very  valuable  instrument  in  the  treatment  of  prostatitis ;  owing  to 
the  early  use  of  this  instrument,  not  one  single  case  went  on  to  sup- 
puration. Its  being  straight  is  objectionable  sometimes. 

"  The  patient,  either  in  the  recumbent  position  or  while  sitting  on 
the  edge  of  a  chair,  can  introduce  this  instrument  with  ease,  since  it  is 
curved  and  has  a  long  handle.  When  in  situ,  it  is  not  uncomfortable 
to  the  patient,  even  in  acute  cases.  In  the  latter  the  protracted  use  of 
iced  water  is  indicated;  in  chronic  cases  the  writer  prefers  water  as 
hot  as  the  patient  can  stand." 

Dr.  Robert  C.  Kemp  f  has  devised  a  rectal  cooler  which  is  quite 
ingeniously  constructed  and  seems  to  be  superior  to  the  German  instru- 
ments, which  consist  of  a  bladder  and  lack  strength  and  stability. 

By  the  use  of  this  bag,  heat  or  cold  can  be  applied  without  wetting 
the  patient,  and  the  apparatus  can  be  easily  carbolized.  It  can  also  be 
used  as  a  simple  water-bag,  by  filling  it  and  corking  the  openings. 

STEAM. 

The  vapor  of  boiling  water  has  long  been  used  as  a  remedial  agent, 
for  the  purpose  of  softening  the  exudation  in  croup,  soothing  the 
congested  mucous  membrane  in  laryngitis  and  pseudo-croup,  and  in 
laryngeal  diphtheria.  The  vapor  is  produced  by  the  so-called  croup 
kettles  which  may  be  placed  alongside  the  patient's  bed.  The  latter 
is  covered  by  several  sheets  secured  like  a  canopy  on  a  frame  fastened 
to  the  bed.  Several  kettles  are  usually  required;  a  good  supply  of 

*  Journal  of  Cutaneous  and  Gen ito-Urinary  Diseases,  May,  1896. 
t  American  Medico-Surgical  Bulletin,  September  26th,  1896. 


308        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

alcohol  should  be  on  hand  to  maintain  the  heat,  or,  what  is  better,  one 
or  more  Bunsen  burners  or  gas  jets  may  furnish  the  required  heat. 
The  steam  may  be  conducted  under  the  canopy  by  rubber  or  tin  tubes, 
the  latter  being  superior.  This  method  of  treatment,  which  has  been 
in  use  since  the  time  of  Trousseau,  is  still  efficient  as  an  adjunct  in 
serious  cases,  or  as  a  means  of  preventing  the  progress  of  laryngeal  in- 
flammation to  the  membranous  stage.  Every  experienced  physician 
has  observed  the  great  relief  obtained  from  this  simple  practice. 

Another  useful  application  of  steam  is  the  part  it  plays  in  the 
Scotch  douche,  which  is  referred  to  in  various  parts  of  this  book.  For 
this  purpose  steam  should  be  furnished  by  a  boiler  under  low  pressure 
and  under  perfect  control.  Care  is  required  to  avoid  condensed  water 
which  sometimes  flows  out  of  the  nozzle  with  the  steam  in  the  begin- 
ning of  the  steam  douche. 

Jansen  claims  *  that  the  steam  douche  diminishes  farado-cutaneous 
sensibility,  and  that  this  is  restored  by  the  cold  douche,  an  explana- 
tion of  the  physiological  action  of  the  alternating  Scotch  steam  douche, 
the  effect  of  which  is  more  intense  than  that  of  the  hot  and  cold  water 
alternations. 

STEAM  AS  A  STYPTIC. 

This  novel  application  of  steam  was  devised  by  Professor  Snegirjow 
and  published  in  the  fourth  volume  of  Professor  Sacharjin's  clinical 
lectures  on  therapeutics.  The  originator  first  applied  steam  as  a  styp- 
tic in  uterine  diseases,  in  the  following  manner  :f 

After  dilating  the  cervix  (without  anaesthesia)  and  curetting  the 
uterus,  he  introduced  into  the  uterine  canal  a  catheter  having  numer- 
ous openings  in  its  distal  end.  The  other  end  of  the  catheter  was  con- 
nected with  the  nozzle  of  a  steam  kettle.  The  steam  was  at  a  tem- 
perature of  100°  C.  After  one  or  one  and  a  half  minutes'  use  of  the 
steam  its  styptic  and  cauterizing  action  was  noticeable;  a  brown 
bouillon-like  fluid  flowed  from  the  catheter. 

The  operation  was  painless.  Its  effect  upon  the  uterus  was  ascer- 
tained by  subjecting  a  uterus  which  was  about  to  be  removed  to  the 
above  treatment  and  examining  it  after  ablation.  The  mucous  mem- 
brane looked  as  though  roasted  and  was  covered  with  a  thin  white  film ; 
all  odor  disappeared  entirely  after  this  operation  and  the  uterus  was  no 
longer  sensitive. 

Added  to  this  cauterizing,  anaesthetic,  and  deodorizing  action  of  the 
steam  its  disinfecting  and  antiseptic  action  makes  it  a  valuable  agent. 

*  Mlinchener  med.  Wochenschrift,  1904. 

fj.  Jaworski,  Monatsschrift  filr  praktische  Wasserheilkunde,  January, 
1895. 


METHODS   OF   COOLING  AND   HEATING   INTERNAL   PAKTS.       309 

It  is  especially  valuable  in  bleeding  from  parenchymatous  organs, 
and  the  author  prophesies  for  it  a  great  future  in  this  connection. 

Professor  Snegirjow  has  removed  pieces  of  the  liver,  lungs,  and 
kidneys  of  animals  under  the  use  of  steam,  without  hemorrhage. 

Despite  the  apparently  corrosive  action  of  the  steam,  union  takes 
place  by  first  intention.  This  was  demonstrated  not  only  in  animals, 
but  also  in  the  human  subject  during  a  coeliotomy. 

It  has  also  been  used  for  the  purpose  of  stopping  hemorrhage  in 
resection  of  the  knee  without  an  Esmarch  bandage  or  ligatures;  am-' 
putation  of  a  carcinomatous  breast;  extirpation  of  growths  in  the 
skin  (carcinoma,  lipoma,  angioma) ;  amputation  of  the  cervix ;  and  in 
myomotomy. 

The  effect  of  steam  upon  a  clot  of  blood,  taken  from  a  uraemic 
patient,  was  ascertained  by  Jaworski.  After  its  application  for  a  few 
minutes  a  thin  film  formed  upon  the  clot,  increasing  in  thickness  until 
after  the  lapse  of  several  minutes  it  was  several  millimetres  in  thick- 
ness. Several  operations  were  performed,  steam  issuing  from  a  Siegel 
apparatus  and  from  a  distilling  apparatus  being  made  to  flow  through 
a  double-current  catheter  having  several  openings. 

M ,  25  years  of  age,  weak  and  miserable,  has  had  an  abortion  with  metror- 

rhagia ;  flowing  for  five  weeks ;  uterus  enlarged,  anteflexed,  and  movable ;  ex- 
ternal cervical  opening  patulous ;  inner  not  so  large.  Much  blood  in  uterus. 
Diagnosis:  Subinvolutio  uteri,  endometritis  (decidualis) ,  post-abortum  metror- 
rhagia.  The  uterus  was  curetted  and  steam  was  applied  after  Snegirjow 's  method. 
The  catheter  caused  slight  pain  on  introduction,  but  this  lasted  only  a  few 
seconds.  The  steam  was  continued  fifty  seconds.  In  a  few  seconds  a  dark 
brown  bouillon-like  fluid  began  to  exude  from  the  catheter ;  at  the  same  time  an 
indescribably  peculiar  odor  was  noticed. 

Several  other  cases  are  cited  with  a  like  favorable  result  in  stopping 
discharge,  bleeding,  odor,  and  pain. 

It  is  important  to  have  superheated  dry  steam.  This  must  have  a 
temperature  of  150°-300°  C.  in  order  to  get  the  best  results. 

Following  the  recommendation  of  Snegirjow,  Ludwig  Pincus,  of 
Danzig,  has  tested  the  efficiency  of  steam  at  a  temperature  of  100°  C.* 
He  "used  an  ordinary  inhalation  apparatus,  to  which  he  attached  a 
safety  valve.  The  steam  pipe  must  be  a  little  larger  than  on  the  ordi- 
nary apparatus.  On  the  end  of  this  a  tube  about  a  foot  and  a  half 
long  is  fastened.  A  catheter  with  many  openings  in  the  end  is  fast- 
ened to  this  and  is  introduced  into  the  uterus.  Some  sort  of  handle  for 
the  hot  catheter  is  necessary.  The  water  in  the  apparatus  is  brought 
to  a  boil  and  the  flame  is  withdrawn.  The  catheter  is  then  introduced 
and  the  lamp  again  lighted." 

This  author  has  used  this  instrument  in  : 

*  Centralblatt  fur  Gynakologie,  1895,  No.  11. 


310        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

1.  A  case  of  carcinoma  uteri  with  profuse  bleeding,  fetid  discharge, 
and  severe  pains  in  the  pelvis. 

2.  In  three  cases  of  cervical  endometritis  with  profuse  discharge. 

In  the  case  of  carcinoma  the  bleeding  and  discharge  stopped  en- 
tirely after  several  applications  of  the  steam.  After  one  or  two  min- 
utes there  was  a  discharge  of  clots  and  particles  from  the  cervix.  In  the 
cases  of  endometritis  the  author  found  that  the  cervix  was  enlarged  and 


FIG.  65.— Diihrssen's  Vaporizer  for  Local  Application  of  Steam. 

the  discharge  and  bleeding  were  invariably  improved.  The  operation 
is  entirely  painless.  In  only  one  case  did  uterine  colic  ensue. 

Diihrssen  (Fig.  65)  summarizes  the  application  of  steam  in  gyne- 
cology  as  follows : 

1.  As  a  haemostatic  it  has  been  successfully  employed  in  cases  of 
non-malignant  post-climacteric  uterine  hemorrhages.  It  has  proved 
curative  in  the  various  irregular  bleedings  met  with  in  connection  with 
catarrhal  fungoid  or  hemorrhagic  endometritis.  It  acts  as  a  palliative 


METHODS   OF   COOLING   AND   HEATING   INTERNAL,   PARTS.       311 

measure  in  certain  cases  of  fibroid  tumor  or  inoperable  carcinoma  asso- 
ciated with  hemorrhages. 

2.  As  a  caustic.     When  nsed  a  sufficient  length  of  time  it  will  de- 
stroy the  mucous  lining  of  the  uterus,  even  to  the  extent  of  obliterat- 
ing the  uterine  canal. 

3.  As  a  bactericide  it  is  found  effective  in  the  treatment  of  gonor- 
rhceal  and  septic  puerperal  endometritis. 

4.  To  reduce  the  bulk  of  the  sublnvoluted  uterus.     It  has  been  fre- 
quently resorted  to  for  this  purpose  with  success. 

5.  In  chronic  suppurating  fistulous  tracts.     Successful  results  are 
reported  in  cases  of  abdominal  fistulae  of  several  years'  duration,  which 
had  resisted  all  other  forms  of  treatment. 

6.  As  a  preventive  -measure  in  cases  of  incipient  uterine  cancer  it  is 
highly  recommended.     He  maintains,  with   Billroth,  Thiersch,  and 
Waldeyer,  that  carcinoma  develops  only  from  epithelial  elements,  and 
that   the   application   of   steam,   destroying   the   entire  intra-uterine 
epithelium,  followed  by   expulsion  of   the  necrosed   tissues,  checks 
further  progress  of  the  disease. 

The  best  results  according  to  Professor  Duhrssen  are  obtained  when 
used  at  the  first  evidence  of  a  discharge  indicative  of  commencing 
sarcoma. 

As  the  method  recommends  itself  on  theoretical  and  bacteriological 
grounds,  I  would  suggest  that  it  be  tried  in  cases  of  puerperal  endo- 
metritis. 

Dr.  Otto  Kiliani  discusses  the  use  of  steam  for  the  severe  hemor- 
rhages which  sometimes  occur  in  the  operation  of  cholecystectomy  on 
separation  of  the  gall  bladder  from  the  liver,  the  latter  sometimes  being 
torn.*  Especially  in  obese  persons  such  bleeding  may  be  fatal.  The 
danger  from  hemorrhage  is  always  enhanced  in  choleemic  persons. 
Eeferring  to  the  Kussian  publication,  Dr.  Kiliani  states,  that  having 
occasion  to  do  many  gall-bladder  operations,  he  experimented  with  Dr. 
Schwyzer  upon  rabbits.  Exposing  a  kidney,  he  cut  it  in  half  and 
stopped  the  bleeding  instantly  by  steam.  Then  he  extirpated  the  kid- 
ney and  stopped  the  flow  of  blood  from  the  renal  artery  and  vein. 
The  abdominal  wound  was  superficially  stitched,  and  the  animal  re- 
covered completely.  The  cooking-process  by  steam  has  no  deterrent 
effect  upon  primary  union.  The  effect  of  steam  upon  the  tissues  is 
slow,  coagulation  is  superficial.  For  stopping  the  flow  of  blood  from 
the  severed  femoral  artery  of  a  dog,  steam  was  applied  three-quarters 
of  a  minute. 

Dr.  Kiliani  demonstrated  a  simple  apparatus.  He  has  applied 
steam  as  a  styptic  in  one  gall-bladder  operation  and  in  two  operations 
*New  Yorker  medicinische  Monatschrift,  February,  1897. 


312        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

for  hepatic  abscess,  and  found  it  very  convenient.  In  one  case  of  ab- 
scess he  found  it  necessary  to  make  an  incision  through  two  inches  of 
liver  tissue,  which  by  means  of  steam  was  rendered  completely  blood- 
less. Besides  the  possibility  of  scalding  the  patients  or  the  operator  by 
clumsy  management,  the  chief  disadvantage  of  using  steam  as  a  styptic 
lies  in  the  fact  that  all  the  tissues  touched  by  it  assume  the  color  of 
boiled  flesh,  and  thus  the  different  structures  cannot  be  distinguished. 

For  Skin  Diseases. — Libersohn  *  was  practically  the  first  to  utilize 
steam  systematically  in  dermatological  practice,  for  which  he  con- 
structed an  ingenious  apparatus.  He  publishes  a  number  of  cases  of 
eczema,  acne,  lupus  vulgaris  and  lupus  erythematodes,  ulcus  cruris, 
sycosis,  treated  with  satisfactory  results  by  the  careful  local  applica- 
tion of  steam. 

Fodor  (loc.  cit.}  has  found  steam  a  valuable  agent  in  the  treatment 
of  eczemas  which  had  resisted  the  most  competent  dermatologists.  At 
first  he  gave  treatment  once  a  day,  later  every  other  day  for  five 
minutes  to  each  diseased  point.  The  application  was  discontinued 
when  oedema  and  decided  redness  were  observed,  the  parts  were  dried, 
treated  with  vaseline,  lanolin,  and  powdered.  Severe  itching  imme- 
diately yielded  to  the  steam ;  the  indurated  and  scaly  spots  disap- 
peared, the  skin  became  soft,  and  in  six  weeks  the  disease  was  cured. 
For  this  purpose  Fodor  has  devised  a  special  apparatus,  f  consisting  of 
an  ordinary  small  metallic  boiler  and  an  alcohol  lamp.  A  small, 
curved  metallic  tube  attached  to  the  boiler  conducts  the  steam  to  a 
piece  of  rubber  tubing,  one  metre  long,  which  is  secured  to  it.  The 
distal  end  of  the  rubber  tube  is  furnished  with  a  short  glass  tube  (held 
within  a  wooden  holder)  from  which  the  steam  issues.  It  is  well  to 
fill  part  of  the  diameter  of  the  glass  outlet  with  a  piece  of  cork,  for 
the  purpose  of  narrowing  the  stream  and  also  to  prevent  condensed 
water  from  issuing  and  scalding.  The  latter  may  also  be  prevented 
by  occasionally  holding  it  downward  to  permit  the  hot  water  to  flow 
away.  The  application  of  the  small  stream  of  steam  is  at  first  made 
at  considerable  distance,  and  approached  more  closely  by  degrees. 
The  water  of  condensation  which  collects  upon  the  skin  must  be  fre- 
quently mopped  away. 

Frost  bites  have  also  been  successfully  treated  by  hot  air  and 
steam.  Bier  $  states  that  swelling,  pain,  and  itching  ceased  at  once, 
and  ulcers  healed  rapidly. 

I  have  had  no  opportunity  to  test  the  mode  of  applying  steam,  and 
refer  to  it  for  the  purpose  of  demonstrating  the  flexibility  of  water  as 

*Klinisch-therapeutische  Wochenschrift,  18,  1899. 
f  Blatter  f.  kliniscbe  Hydrotherapie,  June,  1901. 
JZeitschrift  fur  Chirurgie,  58,  1901. 


METHODS   OF   COOLING   AND   HEATING   INTERNAL   PARTS.      313 

a  remedial  agent  and  the  fact  that  it  may  be  applied  in  any  form  from 
ice  to  steam. 

Bedsores  which  resist  other  treatment  are  favorably  influenced  in 
Goldscheider's  clinic  by  overheated  steam.  Schlesinger  applies  the 
latter  with  the  Duehrssen  apparatus  above  described,  applied  at  a  dis- 
tance of  10  cm.  upon  the  sores  for  five  to  ten  minutes,  and  especially 
upon  the  margins,  which  usually  produce  fresh  granulations.  Neigh- 
boring parts  must  be  protected  with  cotton  or  plaster.  Aside  from 
the  disinfection,  active  hypersemia  is  induced,  which  stimulates  new 
growth.  The  application  may  be  made  daily  at  first;  it  must  be  di- 
minished as  the  sloughing  subsides. 


CHAPTER   XIII. 

THE  INTERNAL  USE  OF  WATER. 

THERE  is  no  fallacy  more  persistent  and  universal  in  the  medical 
mind  than  the  idea  that  the  imbibition  of  large  quantities  of  water, 
irrespective  of  its  temperature,  produces  diuresis  and  removes  patho- 
logic products,  or  in  some  occult  way  purifies  the  organism.  This 
error  originated  and  has  been  maintained  by  observing  increased  flow 
of  urine  in  healthy  subjects  with  unimpaired  vasomotor  systems  and 
circulation,  when  large  quantities  of  water  were  drunk.  Glax  *  and 
others  have  shown  that  the  increase  of  diuresis  depends  more  upon  the 
temperature  of  the  water  imbibed  than  upon  the  quantity — in  health 
as  well  as  in  disease.  This  view  I  have  often  had  occasion  to  confirm 
clinically.  Just  as  the  effect  of  an  external  application  of  water  differs 
with  its  temperature  (and  quantity),  so  do  the  latter  influence  the 
effect  of  the  internal  use  of  water ;  the  primary  effect  being  in  both 
instances  upon  the  local  circulation.  It  should  be  borne  in  mind,  how- 
ever, that  certain  conditions  exist  in  the  one  which  are  absent  in  the 
other. 

1.  The  point  of  (temperature)  indifference  in  the  skin  is  about  92° 
F.,  while  that  of  the  internal  mucous  membranes  is  98.6°  F.  and  over. 

2.  The  duration  of  contact  with  the  skin  is  entirely  under  control, 
while  in  the  stomach  it  is  limited  by  its  tolerance  and  capacity,  by 
reason  of  which  it  is  rapidly  expelled. 

3.  By  reason  of  1  and  2,  local  reaction  is  readily  induced  based 
upon  the  hydrotherapeutic  law  that  brief  impacts  of  decidedly  cold  or 
hot  water  influence  local  reaction  more  positively  than  prolonged  im- 
pacts of  water  nearer  the  "  indifferent  point."     Glax  furnishes  a  resume 
of  investigation  which  shows  that  the  normal  pulse  may  be  reduced  six 
to  thirty  beats  by  drinking  forty-five  ounces  of  water  at  43°  F.  in  doses 
of  nine  ounces  every  six  minutes,  and  that  drinking  warm  water  in- 
creases the  pulse  ten  to  sixteen  beats. 

The  imbibition  of  moderate  quantities  of  cold  water  not  only 
lessens  the  frequency  of  the  pulse,  but  improves  its  quality  and  the 
arterial  tone,  while  the  drinking  of  warm  water  produces  a  relaxation 
of  the  vessel  walls. 

*  "  Lehrbuch  der  Balneotherapie,"  1897. 


THE   INTERNAL   USE   OF   WATER.  315 

Glax  furnishes  an  interesting  series  of  curves  indicating  the  respi- 
ration, outlined  by  Marey's  cylindre  elastique,  and  the  pulse  indicated 
by  the  sphygmograph.  These  curves  show  distinctly : 

1.  Immediately  after  the  drinking  of  cold  water  the  tension  in  the 
vessel  is  enhanced ;  the  deep  inspiration  produced  by  the  swallowing 
of  cold  water  probably  contributes  to  this  result. 

2.  The  pulse  rate  begins  to  fall  decidedly  in  thirty  seconds,  but  a 
positive  increase  of  tension  in  the  arterial  wall  is  not  present,  though 
occasionally  the  dicrotism  is  more  pronounced. 

3.  A  few  minutes  after  the  drinking  of  water  at  6°  C.  (43°  F.)  the 
heightening  of  arterial  tension  is  quite  plain. 

4.  The  repetition  of  the  dose,  in,  say,  five  or  eight  minutes,  con- 
tinues to  reduce  the  pulse  and  increase  arterial  tension. 

5.  The  respiratory  movements  are  increased  after  a  large  quantity 
(1,000-1,250  c.c.,  35  to  43  oz.)  of  water  is  taken. 

The  effect  of  warm-water  drinking  on  the  pulse  was  studied  by  Glax 
and  Klemensiewicz  in  a  diabetic  patient,  thirty-two  years  old,  who 
showed  that  an  increase  of  pulse  rate  and  diminution  of  arterial  tone 
and  an  increase  of  respiration  ensued  after  the  drinking  of  warm  water; 
also  that  an  enduring  relaxation  of  the  arterial  walls  was  produced  by 
the  methodically  prolonged  drinking  of  warm  water.  Friedrich  and 
Strieker  have  made  exact  experiments  with  the  drinking  of  seven  ounces 
of  water  at  different  temperatures,  ascertaining  the  pulse  and  pressure 
with  the  metallic  sphygmometer  of  Basch  on  the  radial  artery.  They 
found  that  the  effects  of  water  taken  internally  appear  very  quickly. 
Cold  water  diminishes  the  pulse,  and  generally  raises  the  blood  pres- 
sure, unless  it  be  very  cold,  when  it  diminishes  it  in  some  cases ;  while 
hot  water,  on  the  contrary,  increases  the  rapidity  of  the  pulse  and 
raises  the  blood  pressure,  and  lukewarm  water  (77°-86°)  diminishes  it. 
The  lowering  of  blood  pressure  is  in  proportion  to  the  lowering  of  the 
temperature  of  the  water  drank,  the  contrary  effect  being  produced  by 
higher  temperatures.  Water  at  a  medium  temperature  (60°  F.)  has 
very  little  effect. 

The  rapidity  of  the  effect  is  enhanced  by  extreme  temperatures, 
but  the  effect  ceases  entirely  within  twenty  minutes. 

These  findings  have  in  the  main  been  confirmed  by  observations 
made  under  the  author's  supervision  in  the  hydrotherapeutic  institute 
of  the  Vauderbilt  Clinic  by  Drs.  Shrady,  Wittson,  and  Cleghorn. 

Glax  says  correctly  that  the  changes  in  the  pulse  ensue  too  quickly 
after  the  drinking  of  water  of  different  temperatures  to  be  the  result 
of  an  increase  of  water  in  the  blood;  they  are  therefore  very  probably 
the  result  of  a  reflex  action  upon  the  vasoinotor  centres.  The  latter 
effect  was  actually  demonstrated  by  the  experiments  of  Spallita  and 


316        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

Tomasini,  who  found  after  the  imbibition  of  cold  water  a  narrowing  of 
the  cutaneous  vessels. 

It  may  therefore  be  stated  with  some  degree  of  positiveness  that 
the  internal  iise  of  cold  and  of  hot  water  has  a  definite  influence 
upon  the  vasomotors,  not  unlike  that  produced  by  their  external  ap- 
plication. 

The  effect  of  the  drinking  of  large  quantities  of  water  upon  the 
blood  and  upon  blood  pressure  has  been  studied  also  by  Friedrich 
and  Strieker.  The  larger  the  quantity  of  water  (above  200  c.c.)  drank, 
the  greater  is  the  effect  upon  the  blood  pressure  and  the  more  enduring 
is  the  effect,  which,  however,  does  not  continue  for  more  than  three  and 
one-half  minutes.  The  imbibed  water  begins  to  appear  in  the  tissues 
in  one  hour,  and  the  entire  quantity  is  eliminated  within  three  and  one- 
half  hours;  large  quantities  (1,000  to  2,000  c.c.)  being  relatively  more 
rapidly  thrown  off  than  smaller  quantities  (500  c.c.).  The  most  re- 
cent investigations  of  Oertel  and  others  demonstrate  positively  that  the 
drinking  of  an  abundant  quantity  of  water  produces  an  evanescent 
thinning  of  the  blood.  As  the  healthy  organism  is  so  constituted  that 
it  rapidly  eliminates  water  taken  internally,  it  follows  that  a  hydrse- 
mic  plethora  is  impossible,  even  when  great  excess  is  committed.  On 
the  contrary,  the  use  of  cold  water  really  acts  as  a  diuretic,  removing 
even  water  not  imbibed.  Warm  water  also  increases  the  urine  for  a 
short  time,  according  to  Glax,  but  if  its  use  is  continued  the  urine  is 
diminished  and  perspiration  increased. 

In  the  Vanderbilt  clinic  the  author  has  found  only  slight  blood- 
pressure  effect  from  water-drinking.  The  diuretic  effect  of  water- 
drinking  does  not,  therefore,  depend  so  much  upon  the  quantity 
imbibed  as  upon  an  increase  of  blood  pressure  produced  by  the  irri- 
tant action  of  cold  and  consequent  increased  force  of  the  blood  streams 
in  the  kidneys.  For  this  reason  it  is  absent  when  water  is  drunk 
lukewarm  and  when  the  heart  is  not  sound.  Hot  water,  having  more 
feeble  irritant  action,  feebly  stimulates  cardiac  action  and  produces 
an  increase  of  blood  pressure,  which  is  followed,  however,  by  loss  of 
tension  and  relaxation.  The  temperature  difference  between  very  cold 
water  (45°  F.)  and  the  gastric  mucosa  (99°  F.)  being  54°  F.,  the  irri- 
tant effect  is  far  more  intense  than  after  hot  water  (120°  F. )  which 
offers  but  21°  F.  difference. 

This  may  seem  on  first  glance  a  reversal  of  a  long-established  be- 
lief, but  a  consensus  of  modern  physiologists  has  established  the  fact 
that  the  elimination  of  fluid  by  rhe  kidneys  depends  upon  the  pres- 
sure with  which  the  blood  circulates  and  the  consequent  enhanced 
force  of  its  stream  in  those  organs,  and  not  so  much  upon  the  quan- 
tity of  fluids  imbibed. 


THE  INTERNAL  USE   OF   WATER.  317 

Not  only  are  the  fluid  portions  of  the  urine  increased  by  the  drink- 
ing of  water,  but  the  elimination  of  solid  constituents,  especially  of 
urea,  also  results  from  it.  That  this  result  is  not,  however,  due  to  an 
increased  breaking  up  of  albumin,  but  simply  to  a  more  complete  solu- 
tion and  consequent  better  elimination  of  nitrogen  from  the  tissues,  is 
established  by  the  investigations  of  Oppenheim  and  confirmed  recently 
by  von  Noorden.* 

Other  secretions  are  also  increased  by  the  drinking  of  water  abun- 
dantly, by  reason  chiefly  of  a  reflex  effect  upon  'the  secretory  organs. 
Heidenhain  and  other  physiologists  have  noticed  an  increase  of  saliva 
and  bile,  by  reason  of  reflex  excitation  of  the  nerves  controlling  the 
vessels  of  the  glands. 

The  local  and  general  effects  of  the  internal  use  of  water  are  prac- 
tically governed  by  the  same  principles  as  the  external  applications. 
They  are  reflex  chiefly,  as  is  evidenced  by  the  abundant  perspiration 
following  the  drinking  of  very  cold  water  in  moderate  quantities  on  a 
hot  summer  day,  and  the  general  refreshment,  aside  from  the  quench- 
ing of  thirst,  which  ensues. 

THERAPEUTIC  INDICATIONS. 

From  the  above-mentioned  physiological  data  with  regard  to  the 
action  of  cold,  warm,  and  hot  water  taken  into  the  stomach,  their  ap- 
plication in  diseased  conditions  is  self-evident. 

In  acute  infectious  diseases  the  administration  of  two  to  four  ounces 
of  ice  water  every  two  hours  increases  the  urinary  secretion  enormously. 
When  care  was  taken  to  have  plenty  of  ice  in  the  water  so  that  its 
temperature  does  not  rise  above  40°  F.,  I  have  seen  the  quantity 
of  urine  rise  to  one  hundred  and  twenty  ounces  per  diem.  The  elim- 
ination of  toxins,  which  is  thus  promoted,  adds  a  powerful  weapon  in 
the  battle  with  these  treacherous  maladies  and  seconds  the  cold  bath 
very  materially  in  this  direction.  Large  quantities  of  water  at  ordi- 
nary temperature,  on  the  contrary,  embarrass  the  efforts  of  the  system, 
because  in  fevers,  as  has  been  well  shown  by  Botkin,  Leyden,  Nau- 
nyn,  and  Glax,  there  is  already  retention  of  water  in  the  system. 
This  is  enhanced  decidedly  by  burdening  the  latter  with  larger  quanti- 
ties. Sahli,  who  is  an  enthusiastic  advocate  of  "  flushings  "  by  hypo- 
dermoclysis,  found  in  a  case  of  mercurial  poisoning  that  the  diuretic 
action  of  his  injection  ceased  whenever  the  patient's  temperature  and 
pulse  indicated  fever. 

In  diseases  of  the  stomach  the  drinking  of  very  hot  water  has  long 
been  recommended  as  an  adjuvant  to  other  treatment.  A  glass  of  ice 

*  "  Lelirbucb  der  Pathologie  des  Stoffwechsels,"  1893. 


318        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

water  taken  on  an  empty  stomach  has  occasionally  served  as  a  good 
stimulus  to  peristalsis. 

Gastric  Catarrh.  —  The  chief  therapeutic  application  of  water- 
drinking  has  been  in  catarrh  and  other  stomach  disorders  in  which 
there  is  an  accumulation  of  mucus  or  fermenting  material;  and  for  this 
purpose  hot  water  alone  has  been  found  useful.  Besides  its  diluent, 
cleansing,  and  antiseptic  effects  upon  the  mucous  membrane  and  con- 
tents of  the  stomach,  the  reflex  effect  of  water  at  high  temperature, 
slowly  sipped,  upon  the  muscular  coats,  is  to  produce  enhanced  motor 
capacity,  which  furthers  the  passage  of  the  digested  food  into  the  duo- 
denum. In  order  to  accomplish  this  therapeutic  aim,  it  is  necessary  to 
observe  certain  rules  in  the  administration  of  hot  water,  which  not  only 
have  the  sanction  of  experience,  but  which  are  also  justified  by  proper 
regard  to  the  rationale  of  its  action.  The  water  must  be  so  hot  that  it 
cannot  be  gulped  down  rapidly ;  it  must  be  sipped  by  tablespoonfuls 
in  order  to  obtain  the  reflex  stimulating  effect  upon  the  blood-vessels 
and  nerves,  and  consequently  upon  the  muscular  fibres  of  the  stomach. 
The  quantity  thus  taken  must  be  not  less  than  half  a  pint  and  not  more 
than  one  and  one-half  pints,  in  order  to  obtain  a  thorough  cleansing 
and  yet  not  overdistend  the  organ.  The  water  must  be  taken  not  less 
than  half  an  hour  nor  more  than  an  hour  before  one  or  more  meals,  in 
order  to  insure  its  removal  from  and  sufficient  rest  for  the  stomach  be- 
fore food  enters  it.  These  conditions  being  carefully  fulfiled,  there  is 
no  remedial  agent  which  affords  so  much  comfort  and  expedites  recovery 
more  effectively  in  subacute  and  chronic  gastric  catarrh,  dilatation  of 
the  stomach,  and  in  some  forms  of  gastric  neuroses,  than  the  sipping  of 
hot  water  before  meals.  The  latter  is  much  abused  by  the  lay  people 
in  all  these  affections,  but  especially  in  gastric  neuroses.  Such  patients 
rarely  come  under  the  physician's  notice  without  having  partaken  of 
hot  water  abundantly  in  all  sorts  of  fashion,  mostly,  however,  just  be- 
fore eating — a  practice  which  is  always  hurtful,  because  it  distends  the 
stomach,  dilutes  the  food  entering  it,  and  thus  embarrasses  the  digestive 
process.  Jaworski  found  in  the  stomach  after  the  lapse  of  a  quarter  of 
an  hour  half  of  the  quantity  of  water  drank,  but  none  remained  after  the 
lapse  of  half  an  hour,  the  passage  of  water  from  the  stomach  differing 
according  to  its  temperature,  that  of  warm  water  being  slower  than 
that  of  cold  water.  Physiologists  are  almost  unanimous  in  the  belief 
that  only  the  very  smallest  quantity  of  water  is  absorbed  from  the 
stomach.  Hence  the  necessity  of  allowing  some  time  to  lapse  between 
the  drinking  of  hot  water  for  therapeutic  purposes  and  the  subsequent 
meal. 

This  simple  procedure,  therefore,  illustrates  the  importance  of  pre- 
cision in  the  methods  of  hydrotherapy ;  also  the  idea  that  these  are  in- 


THE   INTERNAL  USE   OF   WATER.  319 

variably  based  upon  rational  principles — important  facts  which  the 
author  has  endeavored  to  impress  upon  the  reader  upon  every  possible 
occasion. 

In  certain  infantile  diseases  the  internal  use  of  hot  water  is  often 
effective.  The  clearing  of  the  stomach  by  forced  drinking  of  warm 
water  through  the  nursing-bottle  has  often  proved  advantageous  in  my 
practice.  When  in  the  pulmonary  affections  of  young  infants  the 
bronchial  tubes  become  blocked  by  secretions,  or  the  stomach  is  filled 
by  swallowed  mucus,  warm  sweetened  water  is  readily  taken  through 
the  bottle  or  from  a  spoon  or  cup,  and  acts  as  an  emetic  with  great 
relief. 

Contra-indications. — In  dropsy,  i.e.,  accumulation  of  water  in  abnor- 
mal locations,  the  imbibition  of  large  quantities  of  water  has  been  rec- 
ommended by  many  authorities  as  a  diuretic.  That  this  is  a  serious 
error  has  often  been  made  clear  to  the  author.  He  has  abandoned  this 
practice,  therefore,  for  the  opposite  and  more  effective  one  of  with- 
drawing water  and  watery  foods  from  the  dietary  as  much  as  possible. 
When  the  vasomotor  system  has  not  been  seriously  disturbed  so  that 
reaction  is  not  interfered  with,  as  in  early  oedema  from  cardiac  or  renal 
disease,  two  ounces  of  water  at  40°  F.  every  hour  is  my  favorite  pre- 
scription as  a  diuretic.  In  acute  nephritis  small  quantities  of  very  cold 
water,  repeated  at  half-hourly  intervals,  act  quickly  by  local  refresh- 
ment, and  do  not  overtask  the  stomach.  A  diuretic  effect  is  rarely  ab- 
sent. The  author  is  aware  that  the  opposite  treatment  is  advocated  by 
most  physicians,  viz.,  large  quantities  of  warm  water  for  diluent  effect. 
If  the  enormous  labor  which  this  overfilling  of  the  system  with  fluids 
inflicts  upon  the  embarrassed  circulation  of  the  kidney  be  considered, 
it  would  not  be  difficult  to  see  the  advantage  of  smaller  quantities, 
given  for  the  reflex  effect.  Comparison  of  clinical  results  has  too  fre- 
quently convinced  the  author  of  the  superiority  of  the  latter  method. 

Moreover,  Sahli's  observations  show  conclusively  that  while  flush- 
ing the  organism  produces  active  diuresis,  the  latter  ceases  when  the 
body  temperature  is  elevated.  Fever  being  regularly  present  in  acute 
nephritis,  the  diuretic  effect  of  flushing  must  be  neutralized,  and  the 
heart  is  handicapped  by  the  presence  of  this  excessive  quantity  of  fluid. 
The  author  warns  against  acceptance  of  a  practice  which  is  opposed  to 
a  physiological  and  pathological  rationale. 


CHAPTER   XIV. 

PRACTICAL  APPLICATION  OF   HYDROTHERAPY  IN  ACUTE    AND 
CHRONIC  DISEASES. 

UNDER  the  caption  "  Therapeutic  Indications, "  the  foregoing  pages 
contain  many  references  to  the  application  of  hydrotherapy  in  disease. 
These  references  are  necessarily  brief,  and  apply  only  to  the  diseases 
in  which  certain  procedures  are  indicated. 

That  hydrotherapy  is  a  complex  method  of  treating  disease,  which 
admits  of  many  different  procedures  applicable  to  the  varying  conditions 
arising  in  each,  will  be  evidenced  in  the  following  clinical  portion  of 
this  work.  Without  any  desire  to  depreciate  their  use  or  value,  it  may 
be  asserted  that  medicinal  agents,  even  the  most  efficient  and  powerful, 
are  not  capable  of  much  flexibility.  Antipyrin,  for  example,  which 
reduces  the  temperature  in  the  early  stage  of  fevers,  cannot  be  used 
safely  as  the  disease  advances,  when  the  integrity  of  the  heart  becomes 
more  and  more  impaired;  there  is  no  method  of  adapting  it  to  varying 
conditions,  except  in  the  size  of  the  dose,  and,  owing  to  certain  depre- 
ciating effects,  the  dose  is  necessarily  always  made  as  small  as  possible, 
and  the  extent  of  its  effect  is  thus  limited. 

Our  most  trusted  medicinal  agents — digitalis,  aconite,  chloral, 
salicylic  acid,  opium — have  their  fixed  doses  and  methods  of  application. 
Iodide  of  potassium  and  quinine  and  mercury,  our  only  specific  me- 
dicinal agents,  are  susceptible  of  variation  in  doses;  but  their  limitation 
is  fixed,  and  we  cannot  produce  one  practical  result  with  one  method 
of  administration  or  with  one  dose,  and  another  result  with  another, 
according  to  patients'  conditions  and  the  demands  of  each  disease. 
That  modifications  of  therapeutic  effects  may  be  obtained  by  modifica- 
tions of  the  dosage  of  water  shall  be  clearly  set  forth  in  the  following 
chapters.  The  reader  is  urged  to  follow  the  brief  histories  atten- 
tively and  to  note  the  above  facts,  as  illustrated  in  the  progress  and 
development  of  certain  manifestations  in  each  case,  as  a  guide  in  an- 
alogous emergencies. 

This  reference  to  the  limitations  of  medicinal  agents  is  not  intended 
to  deprecate  their  use  On  the  contrary,  the  author  yields  to  no  one 
in  appreciation  of  their  value,  derived  from  observation  at  the  bedside 
during  half  a  century 


HYDEOTHEEAPY   IN   ACUTE   AND   CHRONIC   DISEASES.          321 

In  hydrotherapy  the  physician  possesses  the  most  flexible  agent  of 
his  entire  therapeutic  armamentarium,  an  agent  which  he  may  adapt, 
by  reason  of  the  great  variety  of  procedures  and  the  large  latitude  in 
temperature,  duration,  and  pressure,  to  every  stage  of  every  disease  in 
which  it  can  be  applied  at  all.  Indeed,  the  necessity  for  its  correct  use 
in  any  disease  exemplifies  this  proposition. 

In  the  following  pages,  it  is  my  purpose  to  enter  into  a  detailed 
account  of  the  application  of  water  in  some  of  those  diseases  which  the 
physician  encounters  most  frequently. 


HYDROTHERAPY  IN  TYPHOID  FEVER. 

In  the  chapter  on  the  cold  friction  bath  it  has  been  the  chief  aim 
of  the  author  to  show  that  it  presents  the  most  frequent,  if  not  the 
only,  therapeutic  indication  in  typhoid  fever,  and  to  marshal  such 
evidence  in  support  of  this  proposition  that  the  most  sceptical  reader 
may  find  it  difficult  to  cavil.  While,  however,  the  Brand  method  has 
been  proved  to  be  the  most  successful  treatment  of  the  disease,  there 
are  some  cases  to  which  it  is  not  adapted,  and  there  are  many  others  in 
which  the  diagnosis  is  obscure  in  the  first  stage,  but  which  would  be 
advantageously  treated  by  some  other  form  of  hydrotherapy,  with  the 
result  not  only  of  affording  comfort  for  the  present  but  also  of  insuring 
safety  for  the  future.  As  a  practical  lesson  the  author  purposes  to 
present  the  methods  he  has  found  most  useful  in  mild  and  in  severe  cases 
of  typhoid  fever.  A  careful  examination  of  the  patient  having  estab- 
lished the  approximate  diagnosis  of  an  essential  fever,  the  comfort  of 
the  patient  is  at  once  provided  for  by  some  mild  hydriatric  procedure. 
If  the  rectal  temperature  be  persistently  over  102°,  ablution,  beginning 
with  water  at  80°  and  reducing  the  temperature  of  the  water  five  de- 
grees at  each  repetition,  is  practised  every  hour  until  the  water  tem- 
perature reaches  60°,  at  which  it  is  continued.  Wet  compresses  are 
also  applied  hourly  over  the  abdomen  until  the  body  temperature  reg- 
isters 100°,  every  half-hour  if  it  registers  above  103°.  Ablutions 
(page  104)  are  ordered  every  two  hours,  in  the  same  relation  to  the 
temperature.  If  the  latter  continues  high,  larger  quantities  of  water 
are  used  in  ablution,  and  the  compress  is  applied  every  half-hour. 
The  patient  should  never  be  disturbed  in  natural  sleep  by  any  treatment. 

DIAGNOSTIC  BATH. 

The  author  has  devised  a  series  of  baths  for  the  first  week  of  a 
continued  fever  which  he  has  termed  diagnostic  bath,  because  he  has 
21 


322        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

often  obtained  thereby  a  clew  to  the  early  diagnosis  of  typhoid  fever 
which  has  been  of  immense  value  to  him  before  the  seventh  day.  So 
soon  as  the  rectal  temperature  reaches  103°  F. ,  and  other  symptoms  in- 
dicate a  suspicion  of  typhoid  fever,  the  patient  is  bathed  as  follows : 
The  tub  in  the  bath-room  is  filled  two-thirds  with  water  at  90°  F. ;  the 
patient,  undressed  and  wrapped  in  a  blanket  or  woollen  gown,  is  placed 
on  a  rocking-chair  and  slid  into  the  bath-room.  After  having  his  face 
bathed  with  cold  water,  he  is  placed  into  the  tub  and  bathed  with  con- 
tinuous friction  for  ten  minutes.  This  is  refreshing  and  agreeable  in 
any  febrile  condition.  The  rectal  temperature  is  noted  half  an  hour 
after  the  patient  has  been  replaced  in  bed.  Four  hours  after  bath  the 
rectal  temperature  is  again  noted;  if  it  registers  103°  or  over,  patient 
is  bathed  in  water  at  85°,  and  temperature  noted  half  an  hour  after 
bath.  Three  and  a  half  hours  later  the  rectal  temperature  is  again 
noted,  and  if  it  does  not  register  below  103°,  a  third  bath  at  80°  is 
administered.  The  bath  is  repeated  for  the  fourth  time  under  the 
same  conditions,  but  at  75°,  always  using  active  friction. 

If  these  baths  reduce  the  rectal  temperature  more  than  two  de- 
grees, it  is  probable  that  typhoid  fever  may  be  excluded.  The 
smaller  the  reduction  of  temperature  after  these  baths,  the  more  posi- 
tive the  diagnosis  of  typhoid  fever  becomes,  always  provided  that  the 
described  technique  has  been  followed  with  precision.  Dr.  Musser, 
of  Philadelphia,  has  informed  the  author  that  he  has  found  the  diag- 
nostic baths  useful  in  doubtful  cases.  The  author  deems  this  bath  test 
as  reliable  as  the  lenticular  spots. 

The  compresses  are  applied  during  the  interval  between  baths. 
The  patient  has  now  received  a  sufficient  number  of  baths  to  display 
his  reactive  capacity.  As  soon  as  the  diagnosis  is  made,  a  portable 
bathtub  of  tin  is  placed  alongside  the  bed,  from  which  it  is  separated 
by  a  screen.  This  is  filled  with  water  at  65°-70°,  as  indicated,  and 
now  the  strict  Brand  method  is  pursued. 

Such  is  my  regular  procedure  in  every  case  of  typhoid,  when  no 
obstacles  are  placed  in  my  path  by  relatives  or  by  the  patient.  Al- 
though the  latter  contingency  has  rarely  occurred  to  me  personally,  it 
would  seem  from  my  correspondence  that  many  doubts  arise  in  the 
minds  of  careful  practitioners.  These  may  be  met  by  consulting  the 
chapter  on  objections. 

There  are  several  procedures  open  to  the  practitioner  which  may 
enable  him  to  meet  prejudice  or  ignorance,  provided  he  has  mastered 
the  principle  guiding  his  technique. 

RESUME. — That  the  treatment  of  typhoid  fever  presents  the  most 
pronounced  example  of  the  therapeutic  advantages  of  water  in  acute 


HYDROTHEBAPY   IN   ACUTE   AND   CHRONIC   DISEASES.          323 

diseases  is  well  illustrated  by  its  rationale  and  clinical  results.     The 
following  methods  are  at  the  disposal  of  the  physician : 

1.  Ablutions  and  compresses  until  temperature  reaches  103°  F., 
or  when  strict  cold  baths  are  impracticable. 

2.  The  strict  cold  bath  or  Brand  treatment — a  bath  not  below  65° 
F.  and  not  above  70°  F.  for  fifteen  minutes.     This  is  administered 
every  three  to  four  hours,  with  continuous  friction,  when  the  tempera- 
ture remains  over  102. 5°  in  recto.     A.  bath  the  temperature  and  dura- 
tion of  which  differs  from  this  is  not  a  strict  Brand  bath,  any  more 
than  is  a  bath  the  temperature  of  which  is  elevated  by  adding  warm 
water,  or  lowered  by  adding  ice,  while  the  patient  is  lying  in  it.     While 
every  physician  has  a  right  to  modify  the  bath  to  suit  his  own  views, 
it  is  absolutely  unfair  to  Brand  and  his  method  to  charge  the  good  or 
bad  results  of  a  modified  Brand  bath  to  the  strict  Brand  method.     If 
the  percentage  of  bichloride  or  carbolic-acid  solution,  duration  of  boil- 
ing, or  other  element  of  technique  were  changed  from  that  advised  by 
the  originators  of  strict  asepsis  and  antisepsis,  it  would  surely  be  un- 
fair to  charge  results  from  such  modifications  to  strict  asepsis.     Brand 
has  never  been  fairly  judged  in  his  own  couatry  by  those  who  oppose 
his  methods;    at  least  there  are  no  published  statistics  to  contradict 
the  positive  evidence  furnished  by  reliable  official  records. 

The  statistical  result  (reduction  of  mortality  to  2.7  per  cent),  cor- 
roborated, as  has  been  shown,  ia  various  countries,  declares  this  to  be 
the  treatment  par  excellence  of  typhoid  fever.  Recent  correspondence 
(December,  1907)  with  Professors  Wilson,  Tyson,  and  Musser,  of 
Philadelphia,  James  and  the  lamented  Loomis,  of  New  York,  assures 
me  that  these  colleagues  who  have  enormous  clinical  material  continue 
to  apply  the  Brand  bath,  because,  as  Musser  tersely  expresses  is,  "  we 
get  the  best  results." 

While  the  Brand  bath  is  schematic,  it  is,  as  Mathers  well  says,  the 
most  simple  scheme  for  guidance  of  the  inexperienced,  and,  during  the 
physician's  absence,  for  the  nurses  This  bath  was  first  urged  upon 
English-speaking  physicians  by  the  author  in  February,  1889.  Al- 
though it  met  opposition  it  has  become  the  established  practice  in  the 
larger  hospitals  and  is  taught  in  the  best  medical  schools  now.  Con- 
trary to  the  usual  belief,  the  strict  Brand  bath  is  more  effective  in 
private  than  in  hospital  practice  because  one  of  its  important  elements, 
application  during  the  first  week,  can  rarely  be  met  in  hospital  pa- 
tients. Its  greatest  successes  have  indeed  been  obtained  in  hospitals, 
but  these  were  in  the  army,  where  the  soldier  is  at  once  placed  under 
treatment  when  he  becomes  unfit  for  duty.  It  may  be  useful,  to  those 
who  are  intimidated  by  the  shivering  of  patients  during  or  after  the 


324       THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

friction  bath,  to  suggest  the  solution  of  one  pound  bicarbonate  of  soda 
in  the  bath  water  and  the  addition  of  twelve  ounces  of  hydrochloric 
acid,  or  sufficient  to  produce  C02  bubbles,  which  warm  the  skin  by 
gentle  and  evanescent  irritation,  and  thus  remove  severe  rigors,  which 
must  increase  heat  production.  When  the  disease  has  advanced  to  the 
second  week  or  later,  the  strict  Brand  bath  is  not  safe,  unless  a  milder 
bath,  80°,  for  ten  minutes  intensified  by  a  few  degrees  less,  and  gradual 
increase  of  duration,  has  demonstrated  the  patient's  reactive  capacity. 
The  latter  is  the  chief  guide.  No  intelligent  physician  would  order 
repetition  of  a  bath  after  which  the  patient  remains  pale,  cold,  and 
trembling  for  an  hour.  After  the  first  week  the  strict  Brand  bath 
must,  therefore,  be  modified  to  meet  the  individual  case.  But  clinical 
observation  inculcates  the  lesson  that  whenever  reaction  is  feeble  the 
bath  should  be  made  shorter,  and  not  warmer,  in  order  that  the  ther- 
mic excitation  be  maintained  for  the  production  of  the  reflex  effect 
upon  the  central  nervous  system  and  the  organs  depending  upon  it. 

3.  If  for  any    reason   the    Brand  bath  cannot  be  systematically 
given,  or  if  the  attendant  is  not  convinced  of  its  necessity,  recourse 
may  be  had  to  the  Ziemssen  half-hour  graduated  bath,  in  which  the 
water  at  90°  F.  is  gradually  reduced  to  70°.     Ziemssen  especially  rec- 
ommended these  baths  as  most  useful  in  private  practice,  after  an  ex- 
perience in  several  thousand  cases  during  twenty  years.     He  ordered 
the  temperature  according  to  the  patient's  condition. 

4.  In  a  weakly,  nervous  patient,  in  the  second  week  of  a  neglected 
typhoid,  only  five-  to  ten-minute  baths  from  88°  to  92°,  followed  by 
brief  cold  affusions  or  a  wet  pack  (page  140),  may  be  applied.     The 
temperature  of  the  water  may  then  be  reduced  if  the  effect  is  satisfac- 
tory, and  the  number  and  duration  of  the  baths  may  be  increased. 
The  sum  of  all  the  symptoms  and  the  influence  of  the  bath  upon  the 
entire  case,  and  not  the  temperature  effect  alone,  should  be  the  guide. 
The  statistical  record  of  the  Ziemssen  treatment  in  the  Tubingen  Uni- 
versity Clinic,  from  1877-87,  in  two  thousand  cases,  gave  a  mortality 
of  9.6  per  cent.     The  sheet  bath  (page  118)  and  towel  bath  are  excel- 
lent substitutes  for  the  more  heroic  tub  bath,  provided  the  technique 
is  closely  followed. 

5.  The  hammock  bath  of  Kiess  (page  240)  offers  a  valuable  substi- 
tute for  timid  practitioners  or  timid  patients;  its  statistical  results  are 
more  favorable  (8.5  per  cent  mortality)  than  those  of  the  graduated 
oold  bath. 

6.  The  wet  pack  has  been  used  by  some;  but  experience  has  shown 
its  inadequacy  as  an  antifebrile  agent  and  even  as  an  antithermic 
agent.     Liebermeister  has  shown  that  four  wet  packs,  of  ten  minutes 


HYDROTHEKAPY  IN   ACUTE   AND   CHRONIC   DISEASES.         325 

each,  are  equivalent  to  a  cold  bath  of  ten  minutes.  I  have  ascertained 
that  six  wet  packs  would  be  equivalent  to  a  Brand  bath.  The  choice 
between  these  methods  is  therefore  easily  made.* 

7.  The  Ice  Bub. — Prof.  Hobart  A.  Hare,  of  Philadelphia,  has  de- 
vised a  substitute  for  the  Brand  method,  which  the  author  has  fotmd 
very  useful  in  cases  of  complications  or  conditions  demanding  the 
avoidance  of  disturbing  the  patient.  All  the  good  effects  of  reaction 
are  produced.  The  patient  is  placed  upon  his  abdomen.  A  flat  piece 
of  ice,  wrapped  within  a  piece  of  gauze  or  thin  linen,  is  securely  held 
by  twisting  in  the  right  hand,  and  swept  with  rapid  movements  over 
a  limited  space  of  the  back ;  with  the  left  hand  reaction  is  assisted. 
After  the  rubbed  part  ceases  to  be  warmed,  other  portions  of  the  back, 
the  glutei  and  other  muscular  parts,  are  treated  in  the  same  manner; 
also  the  lower  part  of  the  body,  the  extremities  being  avoided.  Hare 
regards  the  dorsal  muscles  as  great  heat  retainers,  which  cannot  be 
treated  by  friction  in  the  cold  bath.  Although  there  is  no  doubt  that 

*  THE  EXPECTANT  TREATMENT  OP  TYPHOID  FEVER. — In  a  recent  number  of 
the  Medical  Record,  Dr.  Arnot  Spence,  of  New  York,  has  an  interesting  paper 
on  the  expectant  treatment  of  typhoid  fever,  founded  on  the  results  in  323 
cases  treated  in  the  St.  Francis  Hospital  of  New  York  City,  under  the  care  of 
Dr.  J.  H.  Ripley.  Of  the  323  patients  47  died — a  mortality  of  14. 23  per  cent.  Of 
the  47  deaths  12  occurred  within  forty-eight  hours  after  admission.  If  these  are 
omitted,  the  death  rate  is  reduced  to  11.25.  A  specially  interesting  part  of 
the  report  is  that  relating  to  the  cause  of  death.  Leaving  out  the  twelve  mori- 
bund, we  have  eleven  cases  which  were  fatal  either  from  hemorrhage  or  from 
intestinal  perforation,  the  remainder  being  due  to  the  direct  exhausting 
effects  of  the  poison.  Dr.  Spence  appears  to  be  well  satisfied  with  the  results 
of  treatment.  In  the  face  of  results  obtained  by  the  Brand  treatment,  it  is 
strange  to  think  that  any  physician  should  be  satisfied  with  having  a  no  greater 
mortality  than  11  per  cent.  Brand  and  his  followers  would  claim  that  twenty, 
at  least,  of  the  deaths  in  the  cases  reported  might  have  been  prevented  by  the 
cold-water  treatment.  It  is  claimed,  and  we  believe  with  justice,  that  the 
cold-water  treatment  practically  eliminates  deaths  from  broncho-pneumonia 
and  those  due  to  cardiac  failure  from  direct  action  of  the  poison.  Fully  one- 
half  of  the  deaths  in  Dr.  Spence's  tables  were  caused  by  the  above  conditions. 
It  is  more  than  probable  that,  had  a  strict  hydriatic  treatment  been  carried 
out,  the  rate  of  mortality  would  have  been  nearly  a  half  less.  In  private 
practice  the  difficulties  in  carrying  out  the  cold-bath  treatment  are  of  ten  very 
great,  but  in  a  hospital  the  only  excuse  fornot  followingthis  method  of  treat- 
ment is  a  belief  in  the  efficacy  of  other  modes  of  dealing  with  the  disease. 
From  the  results  obtained  by  the  hydriatic  treatment  in  Europe,  and  also  on 
this  side  of  the  Atlantic,  we  believe  that  there  is  overwhelming  proof  that 
the  death  rate  is  much  lower  (probably  from  four  to  six  per  cent)  than  by  any 
other  mode  of  treatment. 

Further,  convalescence  is  undoubtedly  shortened.  That  long  period  of 
physical  and  mental  debility,  so  common  and  so  marked  after  severe  cases  of 
typhoid,  is  seldom  or  never  met  in  cases  treated  with  cold  water. — Montana 
Medical  Journal. 


326       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

this  combination  of  intense  thermic  and  mechanical  stimulation  is  very 
effective,  the  author  would  be  unwilling  to  trust  entirely  to  this  method, 
on  the  therapeutic  maxim  of  Dr.  Hare  that  "  no  therapeutic  measures 
can  be  good  for  all  cases." 

Dr.  Hare  approves  in  this  article  (page  795)  the  statements  on  the 
value  of  "warm  water"  (?)  by  the  Australian  physicians  Hare  and 
Hirshfeld,  concluding  that  "if  it  be  true  that  the  chief  effect  of  cold 
bathing  is  the  production  of  reaction,  then  it  is  conceivable  that  condi- 
tions might  exist  in  which  a  reaction  produced  by  the  use  of  heat 
would  be  better  than  that  caused  by  cold."  The  Australian  statistics 
are  cited  to  demonstrate  this  proposition.  The  mortality  under  the 
cold  bath  was  7. 2  per  cent ;  when  cold  and  warm  baths  were  used  it 
was  7.5  per  cent;  and  when  warm  baths  were  used  (80°  to  90°  F.)  it 
was  only  3.4  per  cent.  Eeaction  is  prodiiced  (page  90)  by  the  differ- 
ence of  temperature  between  the  skin  and  the  water.  It  would  require 
considerable  stretch  of  the  imagination  for  a  patient  with  a  tempera- 
ture of  104°  F.,  for  instance,  to  regard  a  bath  of  90°  as  a  warm  bath. 
Certain  it  is  that  the  reaction  was  not  due  in  these  cases  to  "the  rise 
of  heat."  The  Australian  experience  confirms  the  author's  above 
statement  (fourth)  "  in  the  aged  and  weak  and  children,  a  bath  of  90° 
may  be  more  effectual  than  one  of  85°."  This  confusion  of  bath  tem- 
peratures is  unfortunate.  The  term  cold  and  warm  baths  should  re- 
late to  the  temperature  of  the  patient's  skin  (about  90°).  If  below 
the  latter,  it  would  be  advisable  to  use  the  term  cold;  if  above,  warm 
bath;  in  the  vicinity  of  90°,  the  term  "indifferent  "  would  be  useful. 

If,  as  those  most  experienced  in  the  method  are  agreed,  our  thera1- 
peutic  efforts  are  directed  to  maintenance  of  the  systemic  functions,  we 
have  in  the  methodical  application  of  cold  water  the  most  effective  means, 
because  it  not  only  reduces  the  temperature,  but  it  refreshes  and  invigor- 
ates the  nerve  centres  which  preside  over  the  functions  upon  whose  integ- 
rity depends  the  nutrition  of  the  patient.  Any  judicious  application  of 
cold  water  will  prove  beneficial,  but  experience  demonstrates  that  the 
more  nearly  we  approach  the  ideal  Brand  method,  the  more  positively 
satisfactory  will  be  the  results. 

The  author  would  call  attention  to  the  fact  that  he  has  endeavored 
to  present  the  subject  of  typhoid-fever  treatment  fairly,  imbued  with 
the  solemnity  of  a  task  which  may  be  the  means  of  saving  large  num- 
bers from  the  fatal  grasp  of  this  relentless  scourge.  The  evidence 
before  us  is  clear  and  incontrovertible.  Upon  our  conscientious,  un- 
biassed, and  fearless  judgment  and  action  rests  the  weal  or  woe  of  those 
who  commit  their  lives  iuto  our  keeping.  No  physician  is  expected 
to  yield  his  own  judgment  and  the  results  of  his  own  experience  in 
deference  to  any  method,  be  it  approved  by  ever  so  eminent  an  au- 


HYDRO-THERAPY   IN   ACUTE   AND   CHRONIC   DISEASES.  327 

thority.  But  every  true  physician  is  in  duty  bound  to  examine  the 
rationale  and  the  clinical  results  of  such  a  method  ere  he  condemns  it. 
This  has  never  been  done  by  the  opponents  of  the  Brand  method, 
which  even  so  able  a  clinician  as  Curschman  *  confounds  with  the  anti- 
pyretic and  antithermic  methods  of  Jiirgensen  and  Liebermeister.  With 
incomprehensible  unfairness  and  disregard  of  the  published  facts 
Curshman  writes :  "  At  first  under  the  profound  influence  of  the  labors 
of  Brand  and  his  successors,  and  in  consequence  of  overestimation  of 
the  significance  of  febrile  elevation  of  temperature,  cold  baths  were 
preferably  given  at  temperatures  as  low  as  6°  to  10°  C.  (44°  to  50° 
F.)."  From  personal  correspondence  with  Brand  I  am  satisfied  that 
he  never  in  any  of  his  writings  recommended  a  bath  below  65°  F.,  and 
often  used  it  much  higher.  Moreover,  his  whole  propaganda  was  in 
opposition  to  the  temperature-reducing  idea  and  in  favor  of  the  nerve- 
centre  stimulation  by  the  cold  bath,  which  Curschman  very  justly  advo- 
cates to-day.  It  is  not  surprising  that  under  such  misconception  the 
Brand  method  has  fallen  into  unmerited  desuetude  in  Germany.  In- 
stances of  misunderstanding  the  rationale  and  clinical  aim  of  other 
hydriatric  procedures  are  so  frequent  that  they  have  retarded  the  uni- 
versal appropriation  of  water  as  a  remedial  agent. 

This  somewhat  lengthy  discussion  is  intended  to  present  fairly  the 
most  important  therapeutic  method  of  the  present  time. 

CLINICAL  ILLUSTRATIONS. — The  flexibility  of  hydriatric  methods 
and  procedures,  which  may  be  utilized  in  varying  conditions  and  as- 
pects of  typhoid  fever,  are  illustrated  by  the  following  histories  from 
the  hospital  and  private  records  of  the  author.  A  careful  perusal 
may  serve  the  reader  as  a  guide  in  similar  emergencies,  as  it  is  of  the 
utmost  importance  to  modify  procedures  in  accordance  with  the  indi- 
cation of  each  individual  case.  Hence  these  ^histories  offer  hints  which 
are  not  obtained  in  histories  of  cases  treated  by  drugs. 

CASE  I. — Typhoid  Fever  with  Acute  Infectious  Nephritis — Treated  by  Ablution*, 

Abdominal  Compresses,  and  Free  Internal  Use  of  Water — Recovery. — M.  W , 

aged  thirty-five  years,  a  patient  of  Dr.  Simpson,  residing  at  Hotel  Majestic,  had 
a  chill  on  the  20th  of  September,  1897,  followed  by  fever.  Temperature  ranged 
from  102°  to  106°,  and  pulse  from  120  to  140.  Urine,  examined  by  Dr.  Simpson, 
contained  albumin  and  granular  casts;  quantity  excreted,  twenty-five  ounces  in 
twenty -four  hours.  Patient  exceedingly  nervous,  sleepless,  sometimes  delirious, 
throwing  towels  at  the  nurse,  etc.,  and  altogether  in  an  unpromising  condition. 
On  the  24th  the  quantity  of  urine  passed  was  twenty-seven  ounces.  The  treat- 
ment up  to  this  time  had  been  homosopathic,  combined  with  alcohol  sponges ; 
diet,  milk.  On  September  25th  this  treatment  was  discontinued  and  the  fol- 
lowing ordered :  Five  drops  of  dilute  hydrochloric  acid  (placebo)  every  two 
hours  in  water,  followed  by  six  ounces  of  cold  water,  alternating  with  six  ounces 

*  "Nothnagel's  Cyclopaedia, "  "  Typhoid  and  Typhus  Fevers, "  translated  by 
Alfred  Stengel  and  edited  by  William  Osier,  pp.  455  and  456. 


328       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

of  milk  every  two  hours ,  an  abdominal  compress  at  60°  every  hour.  Tub  bath 
at  85°  when  temperature  reaches  103°. 

September  25th,  urine  contained  albumin  rand  casts.  Temperature,  which 
had  reached  103°  on  the  previous  day,  fell  to  101°  after  the  above  hydriatic  treat- 
,ment  had  been  instituted.  It  fluctuated  between  101°  and  102.5°  for  five  days, 
then  gradually  subsided  until  it  reached  normal  on  October  13th,  reaching  every 
day  above  99°. 

The  pulse  never  exceeded  100  after  this  treatment  was  instituted,  and  averaged 
80  during  the  last  two  weeks.  The  urine  showed  the  most  marked  change.  After 
the  first  twenty -four  hours  of  this  simple  water  treatment  60  ounces  was  passed  ; 
then  followed  87,  92,  98,  117,  113,  123,  90,  116,  82,  109,  82,  112,  81,  83,  90,  76, 
86,  86,  90,  70,  80,  82,  79,  60  oz. ,  by  exact  measurement  of  the  nurse,  Miss  Trous- 
dell.  Albumin  and  casts  disappeared  in  ten  days.  This  case  illustrates  that  a 
severe  type  of  typhoid  fever  may  be  modified  and  carried  to  a  successful  issue  by 
simple  hydriatic  measures  without  cold  baths. 

That  ablutions  are  a  very  efficient  procedure  in  typhoid  fever  is 
demonstrated  by  the  report  of  Dr.  Cabot,  *  who  has  gathered  the  results 
of  one  thousand  cold  baths  given  in  the  Massachusetts  General  Hos- 
pital, two  hundred  being  Brand  baths  (65°,  twenty  minutes  with  fric- 
tion) and  eight  hundred  being  sponge  baths,  of  from  ice  cold  to  65°, 
according  to  the  patient's  temperature,  the  patient  lying  on  a  rubber 
sheet  and  having  the  water  squeezed  over  him  from  a  sponge  and  being 
well-rubbed  with  the  latter.  The  reduction  of  temperature  from  the 
Brand  bath  averaged  2.4  degrees;  the  reduction  from  sponge  baths  0.4 
degrees.  Fewer  tub  baths  were  needed ;  most  patients  liked  the  sponge 
baths,  but  none  liked  the  tub  baths.  The  results  were  the  same  after 
each.  As  a  rule  the  tub  baths  produced  shivering,  cyanosis,  and  feeble 
pulse. 

Dr.  Arthur  V.  Meigsf  used  ablutions  every  two  hours  with  pieces 
of  gauze  dipped  in  cold  water,  with  which  the  entire  body  was  succes- 
sively mopped  and  rubbed.  In  his  report  on  214  cases  treated  by  him 
during  the  Cuban  war,  Dr.  Meigsf  compares  the  results  with  those  ob- 
tained in  cases  treated  by  "cold  plunges."  The  mortality  of  the 
latter  is  claimed  to  have  been  11.58  per  cent,  and  of  the  former 
only  6. 72  per  cent ;  the  exact  temperature  and  technique  are  unfortu- 
nately not  stated;  an  omission  which  renders  a  comparative  estimate 
absolutely  unreliable. 

These  reports  offer  an  excellent  showing  for  ablutions  with  friction, 
but  I  am  disposed  to  believe  that  there  was  some  defect  in  the  tech- 
nique of  the  plunge  to  which  persistent  cyanosis  and  feeble  pulse  may 
always  be  traced.     Indeed,  when  the  latter  occurred,  Brand  himself 
never  continued  the  bath  at  65°,  nor  for  twenty  minutes.     In  such 
cases  either  the  bath  should  be  shortened — Brand's  rule  is  to  remove 
the  patient  from  the  water  at  any  moment  when  cyanosis  ensues — or  it 
should  be  given  at  70°  or  75°.     The  report  of  Dr.  B.  F.  Stahl  in  the 
*  Philadelphia  Medical  Journal,  February  21st,  1899,  p.  411. 
f  Boston  Medical  and  Surgical  Journal,  1893,  p.  290. 


HYDEOTHEEAPY   IN   ACUTE   AND   CHEONIC  DISEASES.          329 

same  journal  furnishes  a  refutation  of  Dr.  Meigs'  claim  in  that  he 
treated  144  cases  by  the  strict  Brand  bath  (for  information  of  which 
the  author  is  indebted  to  Dr.  Stahl)  with  a  mortality  of  2.8  per  cent. 

Kobler*  reports  good  results  when  the  axillary  temperature  was 
38.5°  C.  (101.5°  F.),  from  ablution  with  water  at  14°  to  16°  C.  (57°  to 
60°  F.)  every  two  or  three  hours,  which  produced  excellent  effects 
upon  the  circulation.  The  number  of  cases  in  hospital  was  331, 
mortality  26 — 7.8  per  cent,  whereas  formerly  20  per  cent  mortality 
was  regarded  as  an  average.  Kobler  administered  cold  baths  rarely. 
Here  again  the  importance  of  following  Brand's  technique  strictly  is 
illustrated. 

CASE  II. — Typhoid  Fever  Treated  at  Home  Eleven  Days  without  Baths— Brought 
to  Hospital  in  Desperate  Condition — Brand  Baths  and  Affusions  Change  Aspect  of 
Case — Recovery. — Abstract  830,  furnished  by  Dr.  Rossman,  house  surgeon  of  J. 
Hood  Wright  Memorial  Hospital.  E.  J.  C ,  aged  twenty-seven  years,  admit- 
ted by  ambulance,  November  14th,  1896.  Visiting  physician,  Dr.  Baruch ; 
house  physician,  Dr.  Lewald. 

History :  Thirteen  days  under  treatment  for  typhoid  fever  by  Dr.  Frank 
Daniels  ;  temperature  ranging  from  103°  to  105°,  pulse  from  120  to  150 ;  delirious, 
actively  at  first,  now  muttering. 

Present  condition  :  Is  stuporous ;  responds  when  sharply  spoken  to ;  tongue 
dry  and  brown  ;  teeth  covered  with  sordes ;  skin  much  congested  ;  abdomen  dis- 
tended, tympanitic,  shows  several  rose  spots. 

Ordered  milk,  §  vi.,  and  lime  water,  §  ii.,  every  three  hours. 

E  Dilute  hydrochloric  acid TTJ,  v. 

Water 1  vi. 

S.  Every  three  hours  alternating,  with  milk  every  two  hours. 

Tub  baths  at  80°,  reduced  five  degrees  each  until  70°  is  reached,  for  fifteen 
minutes  every  three  hours,  when  temperature  reaches  103°. 

November  15th.— Abdominal  distention  more  marked.  Has  received  three 
baths  during  the  night,  causing  a  fall  of  one  degree.  Subsultus  and  mental  tor- 
por still  present.  9  P.  M.  ,  turpentine,  TTIX.  every  three  hours.  Temperature, 
102  2°.  Affusions,  60°,  to  head  and  shoulders,  to  relieve  stupor. 

November  16th. — Affusions  at  3  and  6  A.M.  Passed  forty-five  ounces  of 
urine  during  past  twenty-four  hours,  containing  albumin,  hyaline  and  granular 
casts.  Mental  condition  improved. 

November  17th. — Two  affusions  and  three  baths  given  yesterday.  Subsultus 
continues  ;  is  more  stuporous.  Two  ounces  of  strong  hot  coffee  before  and  after 
baths  and  affusions.  Affusions  every  two  hours,  alternating  with  baths  every 
two  hours ;  omit  whiskey.  Temperature  remains  below  103°.  Enema  (turpen- 
tine) removed  distention. 

November  18th.— Mental  condition  the  same.     Affusions  continued. 

November  19th. — Mental  condition  improved.     No  tympanites. 

November  20th.  —Tongue  moist,  appears  almost  rational,  and  asks  questions. 

November  21st. —Temperature,  101°.  Affusions  (cardiac  tonic)  given  every 
four  hours.  At  9  P.M.,  temperature  rose  to  104° ;  pulse,  120.  Tub  baths  given 
at  70° ;  compresses  at  60°  after  bath.  Half  an  hour  later,  temperature,  103. 8° ; 
at  12  P.M.,  temperature,  105°. 

*  Wiener  medicinische  Presse,  1900,  19. 


330        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

November  22d. — Three  baths  given  during  the  night.  Abdomen  distended. 
At  9  P.M.,  temperature,  100°.  Affusions  continued. 

November  23d. — At  3  P.M.  ,  last  affusion. 

November  28th. — For  the  past  four  days  the  temperature  has  been  between 
100  and  102.8°.  Half-pack,  65°,  every  hour. 

November  29th. — At  6  P.M.,  temperature,  103.4°;  full  bath  given  at  70°  for 
ten  minutes. 

November  30th. — Faeces  contains  clots. 

December  1st. — Examination  of  blood,  responsive  to  Widal. 

December  2d. — New  spots  on  abdomen. 

December  4th. — Temperature,  103°;  three  baths  at  70". 

December  5th.  — Three  baths,  70°,  for  ten  minutes. 

December  7th.  — Two  baths. 

December  9th. — Four  baths. 

December  llth. — Temperature  normal. 

December  15th.  — Abscess  in  lower  sacral  region  incised  by  Dr.  Baruch  ;  six 
ounces  of  pus ;  drain  introduced. 

December  20th.  — Eats  light  pudding.     Sacral  wound  healed. 

January  1st,  1897.  — Dr.  Knickerbocker  attending. 

January  2d. — Temperature  rose  suddenly  to  103°  ;  pulse,  132;  respirations, 
34.  At  midnight  temperature  fell  to  100°. 

February  1st. — Patient  discharged  cured. 

Dr.  Frank  Daniels,  who  had  treated  this  desperate  case  until  the  pa- 
tient was  transferred  to  the  hospital,  reported  it  to  the  Harvard  Medical 
Society,  with  the  following  comments :  "  I  have  no  doubt  whatever  that 
this  man  was  saved  by  the  application  of  the  Brand  baths  and  cold  affu- 
sions to  the  head  and  shoulders.  This  case  shows,  better  than  any 
other  I  could  present,  the  advantage  of  this  method  of  treatment. 
Begun  as  it  was  late  in  the  course  of  the  disease,  i.e.,  at  the  end  of 
the  second  or  the  beginning  of  the  third  week,  it  still  was  efficacious." 

CASE  III.  —  Desperate  Case  of  Typhoid  —  Hypostatic  Pneumonia  —  Ablutions  — 
Wet  Compresses  and  Internal  Use  of  ColdWater — Recovery. — Mrs.  P ,  aged  forty- 
five  years,  seen  by  the  author  with  Dr.  E.  J.  Ware  at  midnight,  February  13th, 
1895.  The  patient's  condition  was  so  desperate  that  a  midnight  consultation 
was  held.  When  I  arrived  at  the  house  she  was  engaged  in  a  sad  leave-taking 
from  the  family.  The  patient  had  been  seen  by  several  other  consultants  dur- 
ing the  protracted  course  of  the  disease,  and  hypostatic  pneumonia  had  developed 
which  failed  to  yield  to  the  best-directed  treatment.  Hypodermic  stimulation 
had  been  freely  used  several  hours  before  I  saw  the  patient.  A  compress,  wrung 
out  of  water  at  60°,  covered  with  a  flannel  bandage  and  enveloping  the  chest, 
was  advised,  to  be  repeated  half-hourly  ;  also  gentle  ablutions  of  the  trunk  with 
water  at  70°,  followed  by  drying  of  each  part  for  the  purpose  of  producing  reaction 
before  another  part  was  attacked ;  and  the  systematic  administration  every  two 
hours  of  six  ounces  of  water.  This  simple  treatment  revived  the  flagging  heart, 
visibly  deepened  the  inspirations,  and  refreshed  the  patient.  On  the  following 
day  her  voice  was  stronger,  and  she  expressed  herself  as  much  improved.  The 
case  progressed  very  slowly  to  a  favorable  termination. 

CASE  IV.  —  Typhoid  Fever— Third  Week  — Baths  at  70"  —  Recovery.  —  Mr. 
P ,  aged  thirty-five  years,  was  seen  with  Dr.  L.  A.  Rodenstein,  who  had 


HYDROTHERAPY   IX   ACUTE   AND   CHRONIC   DISEASES.          331 

treated  him  skilfully  with  cold  baths  at  80°,  five  to  ten  minutes  in  duration, 
several  times  daily.  The  patient  was  in  a  precarious  condition — muttering 
delirium,  picking  at  the  bedclothes ;  pulse,  140;  subsultus  and  stupor.  Baths 
of  70°,  fifteen  minutes  in  duration,  with  friction,  and  affusions  at  60°  F.  over 
the  head  and  shoulders,  were  suggested.  The  patient  being  well  advanced  into 
the  third  week,  four  baths  effected  such  a  change  in  his  condition  that  recovery 
became  assured.  The  first  bath  with  affusions  restored  consciousness. 

CASE  V. — Case  of  Typhoid  Demonstrating  Diagnostic  Significance  of  Bath,  and 
the  Value  of  Various  Medicinal  and  Hydriatric  Procedures.  From  iJie  Records  of  the 

Manhattan  General  Hospital. — W.  C ,  married,  aged  thirty  years,  domestic. 

Admitted  May  8th,  1893.  Attending  physician,  Dr.  Baruch ;  house  surgeon, 
Dr.  Covert.  History  (abbreviated)  :  A  week  ago  she  was  taken  sick  with  pains 
all  over  the  body,  headache,  and  general  malaise,  which  have  continued  up  to  the 
present  time.  Lungs  normal ;  heart  sounds  clear  ;  pain  on  pressure  in  right  iliac 
region.  Tongue  coated  brown.  Temperature,  102.2°.  R.  Calomel,  gr.  viii. 
Milk  diet. 

May  9th. — Three  hours  after  her  admission,  temperature  was  105.2°.  Calo- 
mel caused  three  movements ;  she  feels  better ;  pain  in  abdomen  still  severe. 
Temperature,  103.2°. 

May  10th.— Has  had  five  movements  this  morning.  R.  Morphine  sulphate, 
gr.  |,  suppository.  Temperature,  105.4°.  Tub  bath,  water  at  95"  reduced  to  85°, 
to  be  given  every  three  hours  for  fifteen  minutes  when  rectal  temperature  is  102°. 
Reduce  temperature  of  water  two  degrees  each  bath,  till  65°  is  reached.  Naph- 
thalin,  gr.  v.,  every  four  hours ;  dilute  hydrochloric  acid,  f\l  x.  and  water,  6  oz., 
every  four  hours.  Temperature  at  7  :10  A.M.,  105.4°.  Bath  given.  Temperature 
before  bath,  105.4° ;  pulse,  116  ;  respiration,  28.  Temperature  after  bath,  105° ; 
pulse,  112;  respiration,  28.  Temperature  one-half  hour  after  bath,  105.2°;  pulse, 
118;  respiration,  28.  Bath  at  11  A.M.  Temperature  before  bath,  105.6° ;  pulse, 
116;  respiration,  29.  Temperature  after  bath,  105° ;  pulse,  116;  respiration,  29. 
Temperature  one-half  hour  after  bath,  105°  ;  pulse,  116 ;  respiration,  28.  Al- 
though the  patient  has  by  her  clinical  history  been  ill  nine  or  ten  days,  no 
spots  have  appeared  and  there  is  no  splenic  enlargement. 

The  diagnosis  was  obscure.  It  was  at  once  cleared  up  by  the  resistance  of  her  tem- 
perature to  the  baths.  The  writer  has  frequently  noted  this  symptom  in  the  early 
stage  of  typhoid,  and  also  the  fact  that  in  other  diseases  simulating  it,  as  miliary 
tuberculosis,  central  pneumonia,  etc.,  the  temperature  yielded  readily  to  the 
ordinary  reduced  bath.  A  diagnosis  of  typhoid  fever  was  now  unhesitatingly 
given. 

May  llth.— A  few  rose-colored  spots  have  appeared  on  the  abdomen.  Bath 
at  11 : 30  A.M.,  90°  reduced  to  80°.  Temperature  before  bath,  104.2° ;  pulse,  114 ; 
respiration,  28.  Temperature  after  bath,  104° ;  pulse,  112 ;  respiration,  28. 
Temperature  one-half  hour  after  bath,  103.4° ;  pulse,  112 ;  respiration,  26. 
Patient  does  not  react  well ;  shivering  continues  ;  nails  cyanosed.  Hence  it  was 
determined  to  try  the  Riess  continuous  (Hammock)  bath  for  its  antithermic 
effect,  until  the  system  was  in  better  condition  to  resume  the  regular  bath 
treatment. 

Ordered  continuous  bath,  88°,  when  patient's  temperature  reaches  102.5°,  till 
mouth  temperature  is  101°.  Placed  in  bath  at  4  P.M.  Rectal  temperature  before 
bath,  104.4° ;  pulse,  112  ;  respiration,  28.  One  hour  in  bath,  mouth  temperature, 
102.6°;  pulse,  112;  respiration,  32.  Two  hours  in  bath,  mouth  temperature, 
101.4° ;  pulse,  112 ;  respiration,  32.  Three  hours  in  bath,  mouth  temperature, 
102° ;  pulse,  112  ;  respiration.  30.  Four  hours  in  bath,  mouth  temperature,  103° ; 


332        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

pulse,  112  ;  respiration,  30.  Five  hours  in  bath,  mouth  temperature.  103° ;  pulse. 
112 ;  respiration.  30.  Had  a  chill  and  was  taken  out  of  bath.  After  bath, 
rectal  temperature,  102.2°;  pulse,  112;  respiration,  32.  One-half  hour  after 
bath,  rectal  temperature,  102.2°;  pulse,  112;  respiration,  32. 

May  12th.— Placed  in  continuous  bath  at  88°  at  6  :15  A.M.  Rectal  tempera- 
ture before  bath,  103° ;  pulse,  112  ;  respiration,  38.  Patient  became  very  much 
wearied  while  in  these  baths.  Although  they  reduced  her  temperature,  the 
typhoid  countenance  did  not  improve  in  them,  nor  was  the  heart  action  improved, 
demonstrating  that  this  method  is  only  an  antithermic  procedure,  which,  though 
far  superior  to  chemical  antithermics,  cannot  approach  the  Brand  bath  as  a  true 
antifebrile  agent. 

Continuous  baths  omitted.  Patient  being  now  in  better  condition.  Brand  bath 
for  twenty  minutes,  temperature  65°,  every  three  hours  if  temperature  reaches 
102.5.  At  7:10  P.M.,  before  bath,  temperature,  103°;  pulse,  108;  respiration. 
34.  After  bath,  temperature,  103° ,  pulse.  108  ;  respiration,  34.  One-half  hour 
after  bath,  temperature,  101.8° ;  pulse,  106 ;  respiration,  34. 

May  13th. — New  crop  of  spots  on  abdomen  numerous.  Bowels  still  loose  and 
movements  green  in  color. 

Irrigate  bowels  with  water  (temperature,  100°) ,  two  pints,  followed  in  one- 
half  hour  with  starch  water  and  tincture  of  opium,  gtt.  1. 

May  14th. — Brand  baths  were  continued  every  four  hours  until  the  17th,  after 
which  time  the  body  temperature  did  not  reach  the  bathing  temperature. 

May  17th. — Patient  feeling  much  better.  Temperature  at  8  A.M. ,  101°. 
Diarrhoea  has  nearly  ceased,  but  movements  are  still  green  in  color. 

May  27th. — These  baths,  which  have  been  given  every  three  to  five  hours, 
produced  decided  reduction  of  temperature,  as  evidenced  by  the  last  bath  ;  show- 
ing the  greater  antithermic  efficiency  of  the  Brand  bath  in  the  later  days  of  the 
disease. 

Before  bath,  temperature,  104.2°;  pulse,  121;  respiration,  30.  After  bath, 
temperature,  101.4°;  pulse,  114;  respiration,  32.  One-half  hour  after  bath, 
temperature,  99.4°;  pulse,  118;  respiration,  30.  Patient  passed  three  small 
blood  clots  with  faeces,  which  are  becoming  formed.  Baths  ordered  omitted,  to 
give  rest. 

May  29th. — Had  a  movement  without  blood.  Had  a  chill  and  presents 
typhoid  countenance,  dry  tongue,  and  feeble  pulse.  Shallow  hip  bath  at  90°, 
with  water,  three  basins,  at  60°,  thrown  over  the  body,  to  remove  general  nerve 
depreciation  and  invigorate  the  failing  heart.  Affusion  at  6  :30  P.M.  ,  tempera- 
ture being  102.2°;  pulse,  136;  respiration,  38.  Reduced  temperature  to  101.2; 
pulse,  114 ;  respiration,  34. 

May  30th. — Several  affusions  were  given,  the  last  one  showing  a  reduction  of 
temperature  from  103°;  pulse,  130;  respiration,  36;  to  temperature,  102.8°; 
pulse,  116;  respiration,  28.  Patient  fell  asleep.  This  result  illustrates  the 
marked  effect  of  affusions  as  a  heart  tonic. 

May  31st. — Patient  has  grown  stronger  during  the  last  two  days.  The  affu- 
sions intended  to  bring  the  patient  back  to  tolerance  of  the  tub  bath  produced 
the  anticipated  result.  She  now  was  ordered  a  tub  bath  at  70°  for  fifteen 
minutes  every  three  hours. 

June  17th. — These  baths  have  been  administered  about  every  four  hours, 
whenever  the  temperature  reached  102.5°.  That  they  produced  a  most  decided 
reduction  of  temperature  is  evident  from  a  bath  given  at  4 :20  P.M.  Before  the 
bath,  temperature  was  103.2;  pulse,  122;  respiration,  28.  Half  an  hour  after 
the  bath,  temperature  was  99° ;  pulse,  112  ;  respiration,  24. 


HYDKOTHEEAPY   IN   ACUTE   AND   CHRONIC   DISEASES.          333 

That  the  antithermic  effect  of  the  Brand  bath  is  greater  in  the  later  stages  of 
typhoid  fever  than  in  the  first  was  amply  demonstrated  in  this  case. 

June  25th. — The  temperature  reaches  normal  each  morning  and  the  afternoon 
rise  is  becoming  less  each  day.  The  patient  feels  much  stronger  every  day. 

August  20th. — The  patient  is  up  walking  about  the  ward  each  day. 

Remarks. — This  case  is  interesting  and  instructive,  because  it  is  a 
severe  type  treated  by  baths,  until  they  were  contraindicated  by  hem- 
orrhage; then  by  chemical  antipyretics  which,  though  they  reduced 
temperature,  caused  a  return  of  the  typhoid  state.  Heart  failure,  now 
arising,  was  combated  with  cold  affusions,  which  acted  well  and  brought 
the  patient  into  condition  to  bear  tub  bathing,  which  in  the  later  days 
of  the  disease  produced  much  greater  temperature  reduction  than  in  the 
early  days.  This  is  a  characteristic  of  typhoid  fever,  which  should  be 
utilized  more  frequently.  While  the  most  active  hydriatric  procedures 
do  not  influence  the  temperature  very  decidedly  in  the  first  days  of 
the  disease,  mild  measures  become  effective  in  the  later  stages  so 
frequently  that  the  author  has  often  pointed  the  fact  out  to  col- 
leagues. 

Addition  of  chemical  excitants  may  be  utilized  to  great  advantage 
in  cases  with  feeble  reactive  capacity.  The  artificial  Nauheim  salts 
produce,  when  properly  added,  sufficient  COg  to  cover  the  body  with 
bubbles  containing  it  and  thus  aids  in  dilating  the  cutaneous  capilla- 
ries. The  author  recalls  a  desperate  case  to  which  he  was  summoned 
by  Dr.  Joe  Fraenkel,  after  two  other  consultants  had  warned  him 
against  cold  baths.  A  woman  of  forty-five,  in  the  second  week,  had  a 
temperature  of  102°  to  103°,  pulse  160,  reflexes  destroyed,  involuntary 
urine  and  faeces,  no  sleep  iu  forty-eight  hours,  delirious,  was  placed 
by  my  advice  in  a  C02  bath  of  80°  F.  Active  friction  was  added  in 
order  to  promote  peripheral  circulation.  After  the  first  bath  of  15 
minutes  she  fell  asleep.  The  baths  were  continued  every  four  hours, 
interrupted  for  two  days  on  account  of  slight  hemorrhage.  Patient 
became  conscious  after  the  fourth  bath  and  recovered. 

Conclusions. — From  these  histories  it  is  evident  that  the  applica- 
tion of  water  in  fevers  may  be  as  varied  as  are  the  indications  for  its 
use,  and  that  a  correct  appreciation  of  its  mode  of  action  enables  the 
physician  so  to  modify  it  as  to  meet  many  difficulties  and  tide  the 
patient  over  many  dangers.  They  may  serve  as  guides  to  the  manner 
of  meeting  the  indications  that  may  arise.  No  other  remedy  possesses 
the  flexibility  of  water,  and  none  will  afford  the  physician  greater  sat- 
isfaction in  the  management  of  fever  patients. 

Difference  between  Private  and  Hospital  Practice. — Clinical  obser- 
vation clearly  demonstrates  that,  contrary  to  the  prevalent  idea,  the 
Brand  bath  is  more  successful  in  private  than  in  hospital  practice  The 
reason  may  be  found  in  the  fact  that  one  of  the  essential  elements  of 


334       THE  PRINCIPLES  AND  PRACTICE  OF  HYDROTHERAPY. 

the  Brand  bath,  as  of  other  procedures,  is  earliness  of  application. 
The  splendid  statistical  results  of  Brand  and  the  army  hospitals  are 
doubtless  due  to  the  application  of  the  cold  full  bath  before  the  fifth 
day.  This  would  imply  its  application  before  the  diagnosis  is  made. 
The  author  has  outlined  his  own  method,  and  he  feels  safe  in  advising 
this  gradual  but  always  early  adoption  of  cold  baths.  No  possible 
harm  is  done  if  the  disease  proves  to  be  other  than  typhoid ;  while  if 
the  latter  develops,  the  most  important  element  of  treatment  has  been 
instituted,  and  the  apprehensions  of  patient  and  household  have  been 
allayed  by  the  mild  introductory  baths. 

In  hospital  practice  cases  are  rarely  admitted  before  the  second  and 
often  in  the  third  week.  Hence  the  essential  of  earliness  of  treat- 
ment is  impossible.  Moreover,  the  temperature  and  duration  of  the 
bath  demand,  as  has  been  shown,  decided  modification,  adapted  to 
the  stage  of  the  malady  and  the  condition  of  the  patient.  If  the  latter 
has  been  subjected  to  any  form  of  cold  procedure  before  he  reaches  the  • 
hospital,  it  is  the  author's  observation  that  lower  temperatures  and 
longer  baths  may  be  used  with  advantage. 


CHAPTER    XV. 

THE  EXANTHEMATA. 

IN  the  preceding  chapter  reference  has  frequently  been  made  to  the 
application  of  water  in  the  eruptive  fevers.  It  is  the  purpose  in  this 
chapter  to  offer  clinical  illustrations  of  the  author's  practice  in  such 
cases. 

MEASLES. 

Although  this  disease  usually  runs  an  uneventful  course,  many 
cases  are  encountered  by  the  general  practitioner  which  cause  him 
anxiety  and  which  are  the  source  of  distress  and  danger  to  the  patient. 
Especially  difficult  does  the  management  of  this  affection  become 
when,  during  the  later  part  of  its  course,  pulmonary  complications 
ensue. 

The  removal  of  the  etiological  factor  being  at  the  present  time  im- 
possible, the  efforts  of  the  physician  are  directed,  as  in  all  infectious 
diseases,  to  the  enhancement  of  the  resisting  capacity  of  the  patient — a 
practice  which  has  found  frequent  expression  in  these  pages. 

Attention  to  the  hygienic  surroundings  of  the  patient,  to  his  diet, 
and  to  the  alleviation  of  distressing  symptoms  usually  suffices  to  carry 
the  case  to  a  successful  issue.  When,  however,  the  temperature  is  high 
(above  103°),  the  patient  is  restless,  sleep  is  impossible  or  fitful,  and 
cough  is  distressing — all  these  being  manifestations  of  an  intense 
toxaemia  acting  upon  the  nervous  system — a  judicious  hydrotherapy 
may  prove  a  boon  to  physician  and  patient  alike. 

The  prejudice  against  cold  air  in  measles  has  happily  disappeared,  but 
the  prejudice  against  cold  water  still  exists,  even  among  many  medical 
men.  Lay  people  may  readily  be  convinced  of  the  harmlessness  of 
cold  ablutions  or  brief  baths  by  being  reminded  how  the  hand  reddens 
and  grows  warm  when  throwing  snowballs,  and  a  practical  illustration 
by  laving  the  back  of  the  patient,  which  is  usually  most  congested, 
with  a  piece  of  gauze  dipped  in  water  at  75°,  will  quickly  demonstrate 
how  rapidly  reaction  takes  place  and  how  absurd  is  the  idea  of  harm 
from  "  striking  in"  of  the  eruption. 

In  the  milder  forms  of  measles,  when  the  temperature  reaches  103° 
and  the  patient  is  restless,  much  comfort  may  be  afforded  by  a  full 
bath  of  ten  minutes'  duration  at  95°,  repeated  every  four  hours  if 


336       THE   PRINCIPLES  AND   PRACTICE   OF   HYDEOTHERAPY. 

necessary,  the  bath  temperature  being  reduced  five  degrees  each  time, 
until  a  calming  effect  is  produced  or  the  bath  temperature  reaches  70°. 
With  the  latter  temperature  it  is  necessary  to  reduce  the  duration  to 
five  minutes.  The  effect  upon  the  general  condition  of  the  patient  is 
usually  gratifying;  he  falls  asleep,  cough  is  diminished  and  jactitation 
removed.  When  the  patient  or  friends  are  too  greatly  alarmed  by  the 
full  bath,  ablution  with  water  at  the  same  temperature,  applied  with  a 
soft  piece  of  gauze  or  a  wash  cloth,  will  be  found  useful.  In  this  disease 
the  ablution  should  be  rapid  and  active  friction  must  be  avoided. 

Cerebral  symptoms  may  be  successfully  combated  by  a  careful  and 
definite  water  treatment.  Whether  accompanied  by  high  temperature 
or  not,  delirium,  stupor,  muttering,  and  extreme  jactitation  must  be 
energetically  met.  Medicinal  agents,  though  efficient  in  reducing 
temperature,  are  unavailing  for  the  removal  of  the  cerebral  symptoms, 
which  are  due  to  the  circulation  of  toxic  elements  in  the  blood.  Here 
the  rapid  application  of  cold  water  is  a  boon  for  which  the  physician 
will  have  cause  to  be  grateful,  if  he  appreciates  that  the  indication  is 
to  arouse  the  central  nervous  system  by  reflex  action  from  the  cutaneous 
sensory  nerve  endings.  In  these  cases  I  order  the  patient  to  be  placed 
semirecumbent  in  a  half -bath  at  95°  F.,  and  to  have  three  or  four 
basinfuls  of  water  at  75°,  or  less,  thrown  over  his  head  and  shoulders. 
If  this  affusion  does  not  succeed,  a  stream  of  water  at  50°-60°  may  be 
poured  from  a  height  of  a  few  feet  over  the  nucha  and  spine  for  one 
minute,  and  repeated  in  four  or  five  minutes,  the  patient  in  the  mean 
time  being  laid  recumbent  and  rubbed  with  the  bath  water  (95°). 
These  applications  are  the  chief  resource  for  arousing  the  lethargic 
nerve  centres  and  restoring  life  and  activity  to  the  dependent  sluggish 
organs.  How  often  have  I  seen  a  child,  which  has  lain  listless,  moan- 
ing or  tossing  unceasingly  upon  its  couch,  aroused  from  these  conditions 
refreshed  and  invigorated  for  further  combat  with  the  toxins  that 
threatened  to  overwhelm  it!  These  procedures  may  be  repeated  every 
two  hours  or  oftener,  if  the  child  lapses  back  into  stupor.  In  the  in- 
terval much  benefit  will  be  derived  from  the  trunk  pack  at  70°,  if  the 
body  temperature  is  103°  or  over.  The  watchful  physician  will  in- 
augurate an  active  hydrotherapy  as  soon  as  he  descries  the  slightest 
cerebral  manifestations  of  toxaemia.  It  is  the  office  of  this  treatment  to 
prevent  rather  than  to  cure  the  latter. 

The  broncho-pneumonia  or  capillary  bronchitis  complicating  measles 
is  so  frequently  fatal  that  it  is  the  attendant's  duty  to  watch  for  the 
earliest  symptoms  of  failing  respiration.  These  serious  complications 
may  be  easily  forestalled  by  three-hourly  baths  at  90°  reduced  to  80°, 
for  five  minutes,  followed  by  chest  compresses  (p.  142)  at  80°  every  hour. 
Regard  should  always  be  accorded  to  the  fact  that  children  suffering  from 


THE   EXANTHEMATA.  337 

measles  do  not  bear  the  abstraction  of  heat  well.  Hence  brief  procedures 
are  the  best  and  safest  method.  When  the  disease  is  fully  developed, 
and  atelectasis  exists  or  is  threatened  by  reason  of  lobular  infiltration 
which  obstructs  the  interchange  of  gases  and  additionally  intoxicates 
the  brain,  active  measures  are  demanded.  If  the  temperature  is  not 
high,  below  100°,  water  at  60°  sprinkled  on  the  chest  for  a  few  seconds, 
followed  by  friction  with  the  flat  hand  and  repeated  every  five  min- 
utes, or  the  rapid  slapping  of  various  parts  of  the  chest  with  cloths 
saturated  with  water  at  50°,  has  been  found  useful  by  the  writer. 
This  failing,  the  child  may  be  held  over  a  basin  and  water  at  60° 
poured  from  a  pitcher  over  the  spine  and  chest  for  a  few  seconds,  fol- 
lowed by  friction  and  chafing  and  repeated  two  or  three  times  with 
intervals  of  five  minutes.  These  measures  deepen  inspiratory  efforts, 
enhance  oxygenation  of  the  blood,  and  remove  cardiac  embarrassment, 
all  of  which  are  evidenced  by  cyanosis  and  coldness  of  the  extremities. 
The  latter  is  almost  invariably  removed  and  warmth  restored  to  the 
clammy  limbs.  By  these  simple  measures  the  patient  may  be  rescued 
from  the  most  desperate  condition.  The  two-hourly  drinking  of  four 
or  six  ounces  of  cold  water  is  a  measure  which  should  not  be  neglected. 

That  the  writer  does  not  stand  alone  in  the  above  optimistic  view 
may  be  demonstrated  by  the  writings  of  eminent  clinicians. 

Professor  Fiirbringer*  says :  "  In  several  cases  of  measles  compli- 
cated by  pneumonia  with  intense  C02  narcosis,  we  have  applied  these 
baths  for  several  days  and  nights  (up  to  seventy  baths  a  week),  with 
the  result  of  seeing  these  apparently  hopeless  cases  recover.  This 
treatment  affords  decidedly  more  satisfactory  results  than  the  formerly 
adopted  medicinal  treatment." 

Professor  Jtirgensenf  says:  " I  think  that  in  severe  forms  of  infec- 
tion this  method  offers  the  only  hope.  To  be  useful,  we  must  be  mer- 
ciless and  institute  severe  treatment.  The  respiration  is  very  much 
benefited  by  cold  affusions.  The  Priessnitz  compress  is  very  highly 
efficacious." 

Guinon,  the  Parisian  psediatrist,  says :  J  "In  the  malignant  hyper- 
pyretic  nervous  types  of  measles  the  full  bath  is  useful  (71°  to  74° 
for  adults  and  64"  to  88°  for  children),  for  five  to  ten  minutes,  and  re- 
peated every  three  or  four  hours.  For  intense  adynamia  cold  affusions 
are  preferable."  For  convulsions  he  recommends  lukewarm  baths, 
with  cold  affusions,  as  the  head  and  lung  complications  do  not  centra- 
indicate  baths  when  the  temperature  is  high.  Musselier  and  Dielafoy§ 

*"  Real-Encyclopadie,"  No.  13. 

fNothnagel's  "  Specielle  Pathologic  und  Therapie,"  iv.,  1895. 
J  Revue  des  Maladies  de  1'Enfance,  1891. 
§  Archiv  fur  Kinderheilkunde,  1892. 
22 


338        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHEEAPY. 

have  succeeded  in  removing  the  most  pronounced  toxaemic  manifesta- 
tion in  the  first  stage  of  measles  by  cold  baths.  The  latter  do  not  act 
upon  the  high  temperature  alone,  but  chiefly  upon  the  nervous  system, 
which  in  grave  cases  is  usually  completely  depressed,  as  evidenced  by 
delirium  and  adynamia. 

Dr.  von  Becker*  reports  an  epidemic  of  measles  in  which  eight 
hundred  children  were  attacked.  The  mortality  was  slight  and  com- 
plications had  a  favorable  issue,  in  von  Becker's  opinion,  on  account  of 
the  treatment  adopted.  Each  child  received  an  initiatory  bath  at  95° 
for  ten  minutes,  after  which  it  was  wrapped  in  a  woollen  blanket  for 
an  hour.  The  perspiration  was  then  dried  and  the  child  thoroughly 
rubbed.  In  two  hours  a  cold  wet  compress  was  placed  around  the  chest, 
which  was  changed  every  two  hours ;  in  high  fever  a  cold  wet  turban 
was  wrapped  around  the  head.  Three  or  four  baths  sufficed  to  bring  the 
rash  to  a  conclusion ;  bronchitis  disappeared  rapidly  without  expecto- 
rants ;  all  the  usual  complications  were  either  absent  or  without  unfavor- 
able effect.  The  influence  of  this  water  treatment  upon  incipient  cases 
was  still  more  favorable.  As  soon  as  a  case  of  measles  occurred  all  the 
children  in  the  family  were  examined,  and  if  the  spotted  redness  of 
the  gums  was  found  in  any  they  were  subjected  to  the  above  treatment. 

In  America,  Dr.  Hiram  Corson,  an  aged  country  practitioner,  whose 
practical  writings  exercised  great  influence  on  my  own  mind  twenty-five 
years  ago,  says  :f  "In  sixty  years,  with  thousands  of  children  under  my 
care  with  measles,  I  have  never  lost  one  with  that  disease.  I  scarcely 
ever  did  anything  in  measles  except  to  give  a  laxative  and  then  keep 
the  patient  cool.  I  often  sponged  the  whole  body  with  cold  water, 
and  gave  it  copiously  as  a  cooling  remedy." 

The  above-cited  clinical  data  cannot  fail  to  convince  any  reasonable 
reader  of  the  value  of  hydrotherapy  in  measles. 

Conclusions. — As  in  other  diseases,  the  author  has  cited  in  support 
of  his  own  advocacy  of  hydrotherapy  in  measles  the  views  of  well- 
known  practitioners  and  teachers,  whose  testimony  is  unbiassed,  clear, 
and  unimpeachable. 

SCARLATINA. 

This  disease  is  so  often  accompanied  by  serious  manifestations  in 
all  its  stages  that  the  experienced  practitioner  is  always  wary  in  its 
presence.  The  toxic  agent  which  has  invaded  the  organism  cannot 
be  neutralized,  but  its  onslaught  may  be  met  with  measures  which  are 
harmless  to  the  patient  but  extremely  effective  in  carrying  the  case  to 
a  successful  issue.  As  in  other  infectious  diseases,  the  judicious  use  of 
water  enables  the  physician  so  to  enhance  the  patient's  resisting  power 

*  Der  Kinder- Arzt,  November  3d,  1897. 
\  University  Medical  Magazine,  1891. 


THE   EXANTHEMATA.  339 

that  serious  complications  may  be  averted  or  successfully  combated. 
This  is  accomplished  by  maintaining  cardiac  action  at  its  highest  stand- 
ard, which  is  highly  important  in  a  disease  in  which  the  kidneys  are 
menaced.  This  cardiac  enhancement  may  be  most  effectively  induced 
by  cool  or  cold  procedures,  the  reduction  of  temperature,  though  valu- 
able, being  in  my  opinion  secondary  to  it. 

In  the  prodromal  stage  of  scarlatina,  ere  a  diagnosis  can  be  clearly 
established,  and  in  those  cases  in  which  the  eruption  is  imperfect,  with 
or  without  high  temperature,  the  chief  brunt  of  the  disease  is  borne  by 
the  heart,  as  evidenced  by  feeble,  rapid,  and  compressible  pulse, 
mottled  or  cyanotic  skin,  and  apathy.  Here  the  cold  affusions  afford 
a  most  valuable  resource.  A  full  bath  of  100°,  if  the  body  tempera- 
ture is  not  above  this  point,  or  of  90°  if  above  it,  will  in  five  or  ten 
minutes  allay  the  nervous  manifestations,  convulsions,  twitchings,  etc. 
When  these  are  accompanied  by  feeble  heart  action,  the  child  should 
be  held  semirecumbent  by  one  attendant,  while  another  pours  two  or 
four  basinfuls  of  water  at  70°  or  less  over  the  head  and  shoulders. 
After  he  is  dried  and  well  rubbed,  the  patient  is  placed  between 
blankets  to  aid  reaction.  The  affusion  may  be  repeated  hourly  if 
necessary,  the  water  being  reduced  in  temperature  five  degrees  each 
time,  and  the  application  being  made  briefer.  The  change  is  often 
marvellous.  The  cutaneous  venous  congestion  due  to  imperfect  cardiac 
propulsion  gives  way  to  a  bright-hued  congestion,  which  relieves  the 
laboring  heart ;  the  patient  falls  into  a  refreshing  slumber.  Even  if 
the  temperature  rises,  sleep  should  not  be  interrupted  unless  the  pulse 
indicates  heart  failure. 

When  the  disease  is  fairly  established,  the  eruption  well  defined, 
and  the  intellect  clear,  no  treatment  beyond  quiet,  ventilation,  milk  diet, 
and  the  systematic  internal  use  of  cold  water,  alternating  hourly  with 
the  milk,  is  required.  The  disease  is  self-limited,  the  toxins  will 
gradually  be  eliminated,  and  a  successful  termination  is  assured  in  or- 
dinary cases. 

When,  however,  the  temperature  persists  above  103°,  the  pulse 
above  130,  when  the  patient  is  restless  and  sleeps  badly,  the  physician 
will  be  forearmed  by  being  forewarned.  Medication  is  unsatisfactory, 
while  the  most  simple  hydriatic  measures  afford  comfort  and'  neutralize 
danger.  Ablutions  with  the  naked  hand  or  with  a  piece  of  soft  gauze, 
avoiding  active  friction,  with  water  at  90°,  reduced  each  time  one  de- 
gree until  75°  is  reached,  now  come  into  play.  They  may  be  repeated 
every  hour  or  two  hours,  according  to  the  severity  of  the  manifesta- 
tions. It  is  the  author's  practice  to  apply  a  trunk  pack  at  70°  every 
four  hours,  for  the  purpose  of  maintaining  the  effect  of  the  ablutions. 
To  invigorate  the  cardiac  action,  to  increase  the  urine  both  in  quantity 


340        THE   PRINCIPLES   AND  PRACTICE   OF   HYDROTHERAPY. 

tand  in  toxic  contents,  and  to  reduce  temperature,  these  procedures 
are  most  effective,  and  in  many  trying  cases  have  served  me  well. 
Occasionally  I  have  found  it  necessary  when  the  temperature  was 
continuously  high,  above  104°,  to  resort  to  the  gradually  cooled  full 
bath — 95°  reduced  to  80°,  during  five  or  ten  minutes,  with  gentle 
friction — as  an  aid  to  the  above  measures.  Although  patients  suf- 
fering from  scarlatina  bear  abstraction  of  heat  better  than  measles  cases, 
I  do  not  regard  prolonged  cold  procedures  (over  five  minutes  and  under 
75°)  as  safe  in  this  disease.  The  affusions  referred  to  above  are  far 
more  valuable  for  meeting  all  indications,  and  they  should  be  preferred, 
even  if  frequent  repetition  every  hour  or  two  hours  is  demanded. 

The  condition  of  the  skin  in  this  disease  modifies  the  effect  of  cold 
applications  by  reason  of  the  semiparetic  condition  of  its  vessels,  which 
have  lost  to  a  great  extent  their  elastic  tonicity,  and  are  therefore  not 
so  capable  of  responding  to  the  thermic  surprise  (shock)  in  the  latter 
as  in  the  earlier  days  of  the  disease.  For  this  reason  repeated  short 
baths  (dips)  or  affusions  of  water  from  50°  to  60°  are  superior  to  full 
baths.  The  latter  cannot  be  borne  without  friction,  which  always  in- 
creases dermatitis  and  must  therefore  be  avoided. 

Whether  hydriatic  procedures  prevent  nephritis  or  not  I  am  not 
prepared  to  say,*  but  I  would  insist  that  they  place  the  patient  in  better 
form  to  pass  through  this  serious  complication.  Every  cautious  prac- 
titioner examines  carefully  for  evidence  of  the  latterc  If  nephritis 
ensues  during  the  acute  stage  of  scarlatina,  the  above-detailed  treat- 
ment should  not  be  omitted  for  fear  of  any  prejudice  against  cold  ap- 
plications. The  latter  are  so  brief  that  no  possible  harm  can  come  to 
the  internal  organs;  the  improvement  of  cardiac  action  resulting  from 
them  is  a  powerful  weapon  against  nephritis.  When  the  latter  de- 
velops during  the  desquamative  stage,  we  have  in  hot  baths,  followed 
by  dry  packs,  the  most  effective  diaphoretic  measure  for  relieving  the 
inflamed  kidney  of  some  of  its  work.  A  full  bath  of  95°  should  be 
prepared  and  the  patient  placed  in  it;  hot  water,  which  has  previously 
been  gotten  ready  in  pitchers  or  buckets,  may  now  be  added  until  the 
temperature  of  the  water  rises  to  100°  F.  Cool  drinks  and  bathing 
the  face  and  head  in  cold  water  will  prevent  faintness,  which  must  be 
carefully  watched  for.  The  bath  may  continue  half  an  hour  if  no 
unpleasant  manifestations  arise,  and  may  be  repeated  with  profit  once 
or  twice  each  day.  While  the  patient  is  in  the  bath  his  bed  is  pre- 
pared by  spreading  two  woollen  blankets  upon  it,  which  have  been 
warmed  with  hot- water  bags  and  bottles.  On  removal  from  the  tub 
the  patient  is  snugly  wrapped  in  these  blankets  and  allowed  to  remain 

*Vogl  (Miinclmer  raedicinische  Wochenschrift,  1892)  has  no  doubt  that 
cold  baths  render  nephritis  more  rare  and  milder. 


THE   EXANTHEMATA.  341 

for  diaphoretic  effect  an  hour  or  two,  cold  water,  plain  or  mixed, 
with  some  agreeable  syrup,  being  abundantly  given  him  to  promote 
diuresis. 

If  nephritis  persists  long  after  desquamation  has  ceased,  different 
conditions  prevail;  the  cold  pack  is  to  be  preferred.  In  these  cases  the 
author's  recent  experience  is  opposed  to  the  hot-blanket  pack  as  a  dia- 
phoretic measure.  The  wet  pack,  the  coarse  sheet  being  wrung  out  of 
water  at  75°,  or  lower  if  rectal  temperature  be  high  (see  technique,  page 
240),  is  not  only  a  valuable  diaphoretic  measure,  but  aids  in  sustaining 
the  cardiac  systole  and  refreshing  and  soothing  the  weary  little  sufferer. 
Care  should  be  taken  that  assistance  is  sufficient  to  wrap  the  patient  very 
quickly  in  the  cold  sheet  and  very  snugly  in  the  blanket.  Reaction  is 
so  rapid  that  no  prolonged  chill  ensues.  Duration  one  to  three  hours. 

This  treatment  may  be  repeated  once  a  day  or  oftener  when  ursemic 
symptoms  threaten.  That  this  seemingly  heroic  measure  is  useful  is 
attested  by  many  observers. 

Kussmaul  *  has  "  often  seen  in  his  consultation  practice  serious  dysp- 
noea, with  serious  and  even  lethal  results,  from  hot  baths,  while  the 
cold  pack  acted  far  better.  The  subjective  condition  of  the  patient 
was  greatly  improved.  An  energetic  derivation  to  the  skin  was  insti- 
tuted, and  if  the  patient  was  well  covered  with  blankets  after  removal 
from  the  pack  an  abundant  diaphoresis  ensued.  The  blood  pressure 
was  always  diminished  by  the  wet  pack,  and  returned  to  its  original 
high  point  only  after  considerable  lapse  of  time." 

The  condition  of  the  patient,  the  immediate  result  of  the  treat- 
ment, must  guide  the  medical  attendant  in  the  selection  of  hot  or  cold 
procedures.  The  fact  should  be  borne  in  mind,  however,  that  the  wet 
pack  really  produces  a  stimulating  effect  upon  the  cutaneous  surface; 
its  initial  action  is  that  of  a  cold  procedure,  the  reaction  producing 
decided  hypersernia.  The  rationale  of  whatever  procedure  is  used 
should  be  clearly  before  the  practitioner's  mind;  his  action  should  not 
be  empirical,  but  judiciously  arranged  in  accordance  with  the  thera- 
peutic indications  which  are  present.  Only  in  this  wise  may  the  ap- 
parent paradoxes  of  cold  and  hot  applications  be  cleared  up  and  made 
to  inure  to  the  benefit  of  suffering  humanity. 

That  the  treatment  adopted  by  the  author  and  above  outlined  is 
the  most  useful  in  scarlatina  finds  ample  corroboration  in  the  publica- 
tions of  justly  eminent  and  trustworthy  observers.  Among  the  latter 
the  following  may  be  cited  as  illustrating  the  methods  most  practised 
by  clinical  teachers : 

Guinon  gives  f  precise  directions  for  the  use  of  water  in  measles. 

*  Berliner  klinische  Wochenschrift,  July  9th,  1898. 
t  Revue  Mensuelle  des  Maladies  de  1'Enfance,  1892. 


342       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

"  There  are  three  great  indications  to  moderate  the  fever — quiet  nervous 
disturbances  and  prevent  and  combat  the  secondary  infections.  Anti- 
pyretics should  be  avoided.  Hydrotherapy  certainly  provides  more 
efficient  means  and  is  easier  of  control.  Cold  baths  are  the  selective 
method  of  Guinon  in  persistent  pyrexia  and  adynamia  of  scarlatina, 
when  there  is  no  cyanosis  or  feeble  pulse.  Pulmonary  complications 
are  favorably  influenced  by  them." 

Guinon 's  views  with  regard  to  variola  may  appropriately  be  quoted 
here,  since  this  disease  will  not  be  separately  treated  in  this  work.  He 
finds  cold  baths  eminently  useful  to  overcome  the  nervous  accidents  and 
moderate  suppuration.  "  Tepid  baths  decrease  pain  and  warm  baths 
are  cleansing.  In  the  invasion  stage,  with  dyspnoea,  somnolence,  and 
temperature  of  104°,  cold  baths  (64°  to  68°  F.)  for  adults,  70°  to  74° 
F.  for  children,  should  be  used  systematically,  and  in  sudden  emer- 
gencies cold  affusions.  These  cold  baths  do  not  check  but  favor  eruptions 
and  diuresis." 

This  dictum  of  the  eminent  Parisian  paediatrist  should  be  borne  in 
mind  when  any  doubt  arises  with  regard  to  cold  applications  in  any  of 
the  eruptive  fevers. 

Baginsky*  expresses  himself  as  follows :  "  Our  therapy  has  to  fulfil 
two  indications — to  moderate  fever  and  prevent  complications.  Both 
indications  are  fulfilled  by  baths.  In  the  most  grave  complication  of 
scarlatina,  nephritis,  the  suppression  of  cutaneous  function  by  the  dif- 
fuse dermatitis  is  etiologically  concerned,  and  therefore  attention  to 
the  skin  stands  at  the  head  of  our  therapy.  It  is  sufficient  in  mild  cases 
to  keep  the  skin  clean ;  in  more  severe  cases  it  is  advisable  to  bathe 
frequently." 

Schill,  of  Wiesbaden,  has  contributed  an  excellent  statistical  and 
practical  article  on  the  bath  treatment  of  scarlatina,  f  in  which  he  re- 
lates one  hundred  and  ten  cases,  treated  by  himself  and  Schellenberg 
with  daily  baths,  95°,  for  ten  minutes,  twice  a  day  in  the  first  week 
and  only  daily  in  the  second  week.  Nephritis  or  albumin  did  not 
occur  in  any  case,  and  the  progress  of  the  disease  was  rendered  mild 
by  this  simple  treatment. 

Comby,  the  eminent  paediatrist  of  the  Hopital  Trousseau,  J  "  regards 
cold  water  in  the  exanthemata  as  refreshing,  derivative,  heart  invigor- 
ative, diuretic,  tonic,  and  sedative." 

Guerin§  is  an  enthusiastic  advocate  of  frequent  but  brief  cold  baths 
(78°  F.)  in  the  grave  forms  of  scarlatina  and  measles,  which  demand 
imperatively  their  immediate  use.  Under  their  influence  the  function 

*"Lehrbuch  der  Kinderkrankheiten,"  Berlin,  1896. 
f  Therapeutisehe  Monatshef  te,  No.  43,  1896. 
j  La  Medecine  Moderne,  No.  1,  1897. 
§  Gazette  des  Hdpitaux,  February,  1891. 


THE   EXANTHEMATA.  343 

of  the  kidneys  is  rapidly  restored  and  a  very  good  impression  is  made 
upon  existing  bronchitis  or  pneumonia.  Guerin's  views  are  shared  by 
Kegnault. 

Professor  Jurgensen*  considers  "  cool  baths  the  best  treatment  of 
scarlatina  from  its  invasion  to  its  cessation.  The  toxic  manifestations 
and  elevated  temperature  can  be  successfully  combated  only  by  the 
use  of  water.  Baths  of  short  duration  (60°  to  70°  F.)  have  a  marked 
beneficent  effect.  Hot  baths  in  the  later  stages  prevent  ursemic  in- 
toxication and  improve  diuresis." 

A.  Vogl,  medical  director  in  Munich,  to  whom  the  world  owes  so 
much  for  advancing  the  Brand  method  in  typhoid  fever,  writes  :f  "  A 
treatment  which  is  capable  of  banishing  the  most  extreme  danger,  even 
when  resorted  to  late  in  the  disease,  must  be  better  adapted  to  the 
earlier  stages;  in  severe  epidemics,  cold  baths  (68°  F.  for  fifteen 
minutes,  when  rectal  temperature  reaches  103°  F.)  change  the  aspect 
of  the  case  on  the  second  day."  Nevertheless,  he  does  not  advise  these 
baths  in  mild  epidemics.  In  the  benign  scarlatina  epidemic  of  1894-95, 
he  applied  them  rarely,  although  three  hundred  and  eleven  soldiers 
were  treated.  In  the  severe  epidemic  of  1884-85  almost  every  one  of 
the  one  hundred  and  twenty-five  soldiers  received  cold  baths,  which 
prevented  nephritis  often.  "  One  will  not  lay  himself  open  to  an  accu- 
sation of  neglect,  if  in  a  benign  epidemic,  even  with  a  rectal  tempera- 
ture of  106°,  systematic  bathing  is  omitted ;  but  it  is  our  duty  to  adopt 
the  latter — i.e.,  bathe  every  suspicious  patient,  even  if  the  rectal  tem- 
perature is  not  above  103°  F. — if  the  course  of  the  cases  indicates 
malignancy." 

In  nephritis  of  scarlatina  the  warm  bath  has  long  been  a  favorite 
remedial  agent.  Unfortunately  the  temperature  and  duration  of  these 
baths  are  rarely  stated  in  the  clinical  reports,  and  the  results  are  cor- 
respondingly undetermined  when  the  practice  is  followed  by  the  unini- 
tiated. The  author  well  remembers  a  case  of  scarlatina  which  he  saw 
in  consultation,  when  he  discovered  to  his  dismay  that  baths  beginning 
with  110°  F.  gradually  reduced  to  60°  had  been  used.  In  view  of  the 
rationale  of  the  warm  bath  it  is  not  surprising  that  the  child  succumbed. 

As  in  other  cases  of  nephritis  the  tub  should  be  placed  alongside 
the  bed,  the  patient  gently  removed  to  it.  The  bath  is  given  sitting, 
immersed  to  the  neck,  or  recumbent,  or  alternately  sitting  and  recum- 
bent, for  one  to  one  and  one-half  hours.  During  the  absence  of  the 
patient  in  the  tub,  the  bed  should  be  arranged  and  filled  with  hot- 
water  bags  to  maintain  its  warmth  until  the  patient  returns  to  it  from 
the  bath.  The  latter  should  have  a  temperature  of  100°  if  the  rectal 

*  Op.  cit. 

\  Munchner  raedicinischc  Wochenschrif t,  1892. 


344       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 


temperature  is  above  this  point;  if  it  is  normal,  the  water  temperature 
should  be  95°  F.  The  tender  condition  of  the  skin  precludes  friction; 
the  feet  and  hands,  however,  should  be  gently  kneaded  to  maintain 
their  warmth.  Ice  water  in  small  quantities  is  to  be  sipped  frequently, 
and  the  face  bathed  with  cold  water  during  the  bath,  which  ma}7  be 
continued  for  one-half  to  one  and  one-half  hours,  unless  the  patient's 
condition  forbids.  The  precautions  here  inculcated,  together  with 
gentle  suasion,  will  serve  to  prevent  the  latter. 

In  view  of  the  excellent  investigations  of  Strasser,  the  action  of  this 
continuous  bath  is  theoretically  and  practically  demonstrable.  The 
author  regards  this  simple  treatment  so  important  that  he  would  re- 
produce the  findings  of  Strasser  in  order  to  further  a  method  which 
has  saved  many  lives. 

.ry-rtir:  •   '•*  .". 

EFFECT  OF  BATH  TREATMENT  (NEUTRAL  TEMPERATURE)  IN  A  CASE  OF 
SCARLATINAL  NEPHRITIS,  WITHOUT  CHANGE  OF  FOOD  OR  DRINK. 


January. 

Quantity 
of  Urine. 

Specific 
Gravity. 

Total  N 
without 
Alb.  N. 

Albumin 

N. 

Albumin, 
in 
Grammes. 

NaCl. 

Remarks. 

24 

885 

1010 

6.6844 

0.1920 

1.200 

6.549 

After  bath. 

25 

820 

1011 

6.1708 

0.2006 

1.2537 

4.592 

Without  bath. 

26 

915 

1010 

6.8918 

0.1537 

0.9606 

5.673 

After  bath. 

28 

910 

1010 

8.3184 

0.1537 

0.9606 

6.552 

After  bath. 

29 

775 

1011 

6.8515 

0.1464 

0.9150 

4.185 

Without  bath. 

30 

920 

1011 

7.2062 

0.1424 

0.890 

5.704 

After  bath. 

31 

975 

1012 

8.313 

0.1501 

0.9313 

7.215 

After  bath. 

In  the  presentation  of  this  subject  the  author  has  endeavored  to 
offer  a  fair  statement  of  his  own  practice  and  observation,  fortified  by 
the  views  of  physicians  whose  abundant  hospital  material  and  good 
reputation  entitle  them  to  the  highest  consideration. 


CHAPTER  XVI. 

PNEUMONIA. 

THE  history  of  the  treatment  of  pneumonia  illustrates  that  its  suc- 
cess or  failure  is  in  proportion  to  a  correct  understanding  and  mastery 
of  the  nature  of  the  disease.  An  impartial  review  impels  the  author 
to  believe  that  we  have  now  reached  a  view  of  croupous  pneumonia 
which  will  contribute  more  to  the  saving  of  lives  than  all  the  doctrines 
and  remedies  suggested  since  the  days  of  Hippocrates.  The  student 
is  no  longer  taught  that  the  pneumonia  patient  dies  from  apncea. 
Heart  failure  is  the  spectre  that  nmv  stands  at  the  bedside  of  the  patient 
in  this,  and  for  that  matter  in  most  other  acute  diseases,  and  the  chief 
therapeutic  aim  should  be  to  prevent  it. 

The  view  that  pneumonia  is  an  infectious  disease,  whose  chief  rec- 
ognizable lesion  is  in  the  lungs,  but  whose  lethal  tendency  is  in  the 
overwhelming  of  systemic  force  and  vigor,  is  obtaining  more  and  more 
recognition. 

I  would  even  go  farther  than  this.  Careful  clinical  observation 
and  a  judicious  sifting  of  the  testimony  of  reliable  practitioners  have 
brought  me  to  the  belief  that  croupous  pneumonia  is  no  more  a  lung 
disease  than  is  typhoid  fever  a  bowel  disease.  Whenever  this  doctrine 
shall  receive  universal  acceptance,  we  shall  cease  to  treat  the  disease, 
and  we  shall  be  prepared  for  a  more  effective  management  of  the  patient 
suffering  from  it. 

The  great  American  clinician,  Austin  Flint,  called  it  "  pneumonic 
fever"  in  1877,  and  pointed  out  its  analogy  to  typhoid  fever.  Two 
hundred  years  ago  Huxham  had  also  insisted  upon  the  infectious  char- 
acter of  pneumonia. 

The  analogy  of  croupous  pneumonia  to  typhoid  fever  may  be 
discovered  in  its  etiology,  symptoms,  and  course.  The  Sternberg- 
Fraenkel  diplococcus  is  an  important  factor  in  the  production  of  crou- 
pous pneumonia,  being  present  in  about  seventy-five  per  cent  of  cases. 
The  presence  of  some  constitutional  depression  is  a  potent  etiological 
factor.  Age  is  a  predisposing  and  exempting  factor,  inasmuch  as 
young  children  are  rarely  attacked ;  while  it  is  most  prevalent  among 
adults,  and  liability  to  it  diminishes  with  advancing  years. 

Typhoid  fever  presents  analogous  conditions.     In  pneumonia  we 


346       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

have  practically  the  same  manifestations  which  characterize  typhoid 
fever,  differing  only  in  regard  to  the  habitat  of  the  micro-organism, 
diarrhoea  taking  the  place  of  cough.  The  fever  runs  a  different  course 
because  of  the  difference  in  the  life  period  of  the  organisms  involved 
in  each  disease. 

The  most  striking  and  important  similarity  is  that  the  chief  point 
of  attack  in  both  diseases  is  upon  the  nervous  system;  the  toxcemia  result- 
ing from  the  life  and  death  of  the  micro-organism  spends  its  chief  force 
upon  the  nerve  centres.  This  explains  the  well-recognized  clinical  fact 
that  the  general  symptoms  are  rarely  a  correct  index  to  the  local  lesion. 
Dyspnoea  and  fever  especially  may  be  extreme,  and  the  case  may 
terminate  fatally,  with  slight  involvement  of  the  lung,  just  as  we  may 
observe  the  most  serious  general  condition  in  typhoid  fever,  without 
evidences  of  local  lesion  in  the  intestines. 

Crisis  in  croupous  pneumonia  is  signalized  by  complete  cessation  of 
all  the  general  symptoms,  because  the  life  period  of  the  micro-organ- 
isms is  terminated.  And  yet  the  lung  remains  more  or  less  solidified 
by  exudates,  as  is  evident  from  the  physical  signs  continuing.  So  do 
the  general  symptoms  of  typhoid  fever  cease  with  the  cessation  of  the 
life  period  of  the  Eberth  bacillus,  although  the  intestinal  lesions  are 
still  so  far  from  being  removed  that  great  care  needs  to  be  exercised 
with  regard  to  diet,  rest,  and  other  preventive  measures. 

The  prognosis  of  croupous  pneumonia  and  that  of  typhoid  fever  have 
a  close  resemblance  in  many  respects.  The  effect  of  previous  mode  of 
life,  habits,  and  environment,  before  and  during  the  illness,  upon  the 
issue  of  the  case,  is  very  much  alike  in  both  diseases,  as  is  the  influence 
of  childhood  upon  the  prognosis. 

This  brief  presentation  of  the  close  analogy  in  the  etiology,  symp- 
toms, and  prognosis  of  these  diseases  points  to  the  expediency  of  fol- 
lowing in  pneumonia,  as  far  as  the  differences  indicated  above  may 
admit,  the  line  of  management  which  has  afforded  the  best  results  in 
typhoid. 

We  have  learned  from  sad  experience  that  the  chief  indication  in 
typhoid  fever  must  be  to  enhance  the  patient's  resisting  capacity  to  the 
lethal  agencies  evolved  by  the  infection  process. 

It  is  the  aim  of  these  pages  to  emphasize  a  similar  course  of  action 
in  pneumonia.  The  management  of  the  pneumonia  patient  which  is 
here  presented  is  the  result  of  an  evolution  from  the  methods  which  I 
have  been  taught  and  have  practised  for  many  years.  Until  a  few 
years  ago  I  felt  as  helpless  in  a  case  of  pneumonia  as  I  did  at  that 
time  in  typhoid  fever.  Eecovery  in  both  diseases  seemed  to  be  the 
result  of  conditions  over  which  my  control  was  feeble  or  lacking.  The 
patient's  constitution,  the  type  of  the  disease,  and  his  environment 


PNEUMONIA.  347 

played  the  chief  role.  Treatment  was  symptomatic  in  both  diseases ; 
expectant  it  was  termed — and  not  inaptly,  for  something  was  always 
expected  to  happen  which  the  physician  seemed  powerless  to  prevent. 
When  the  true  principles  and  value  of  the  Brand  method  in  typhoid  fever 
became  known  and  appreciated,  a  positive  treatment  was  at  command, 
by  which,  if  employed  early,  serious  and  fatal  complications,  against 
which  we  were  formerly  impotent,  could  be  prevented.  For  the  comfort 
and  the  sense  of  security  derived  from  this  method,  since  I  mastered 
its  technique,  I  shall  ever  be  grateful  to  its  author. 

It  has  been  my  ardent  desire  to  reach  a  similarly  comforting  atti- 
tude in  pneumonia.  Weary  of  the  expectant  plan,  and  observing  its 
enormous  fatality,  especially  in  those  depreciated  by  faulty  modes  of 
life  and  habits,  I  looked  to  hydrotherapy  for  succor.  While  the  latter 
has  not  reached  an  entirely  satisfactory  degree,  observation  and  reflec- 
tion have  evolved  a  method  of  management  whose  clinical  value  de- 
serves to  be  further  tested. 

The  prevailing  type  of  the  disease  should  be  carefully  considered. 
The  vaunted  success  of  certain  methods  of  treatment  may  be  attributed 
to  a  change  of  type  in  the  disease  and  the  previous  conditions  of  the 
patient.  Any  new  treatment  should  therefore  be  approached  with 
caution  and  judgment. 

The  type  of  pneumonia  common  in  New  York  City  appears  to  be 
grave.  In  hospital  and  private  practice  this  disease  is  more  fatal  than 
any  other  acute  disease  of  adults.  In  the  New  York  City  Board  of 
Health  statistics  it  ranks  next  to  phthisis  in  fatality.  The  chief  reason 
of  the  great  fatality  may  be  sought  for  and  found  in  the  helplessness 
of  physicians  in  the  presence  of  this  fearful  disease. 

Complete  rest  of  body  and  mind  and  good  nursing  are  essentials  in 
furthering  recovery.  This  cannot  be  too  earnestly  urged  upon  the  pa- 
tient and  his  family.  The  ventilation  of  the  sick-room,  too,  which  is 
much  opposed  by  the  laity,  should  be  anxiously  watched  by  the  medi- 
cal attendant,  who  is  too  prone  to  yield  to  existing  prejudices,  and  thus 
to  become  an  unwilling  accomplice  in  depriving  the  patient  of  this 
greatest  pabulum  in  infectious  diseases — fresh,  pure  air.  The  patient 
and  family  should  be  positively  assured  that  there  is  no  danger  of  tak- 
ing cold  if  the  body  temperature  is  elevated  to  any  considerable  extent. 
In  summer  and  winter  the  air  of  the  sick-room  should  be  constantly 
renewed,  even  at  the  cost  of  reducing  its  temperature  to  an  extent 
which  in  winter  may  be  uncomfortable  to  the  nurses.  During  the  late 
war  cases  of  pneumonia  treated  in  tents  in  rigorous  weather  did  far 
better  than  those  treated  in  improvised  hospital  buildings.  This  prac- 
tice the  author  has  pursued  and  advocated  for  many  years,  and  it  is  a 
gratifying  confirmation  of  its  value  that  several  clinical  teachers  have 
recently  adopted  it. 


348        THE   PRINCIPLES   AND    PRACTICE   OF   HYDROTHERAPY. 

Oilman  Thompson  and  Northrop  have  demonstrated  that  exposure 
to  extreme  cold  even  is  not  only  devoid  of  unfavorable  effects,  but  con- 
tributes vastly  to  the  enhancement  of  the  patient's  resisting  powers, 
which,  after  all,  is  the  chief  aim  in  the  management  of  pneumonia. 
The  fear  of  exposure  to  cold  in  pneumonia  which  is  so  engrafted  upon 
the  minds  of  medical  men  is  proven  illusory  by  the  statement  of  Oilman 
Thompson,  made  personally  to  the  author,  that  when  in  the  absence  of 
other  facilities  for  affording  his  pneumonia  patients  in  Belle vue  Hos- 
pital the  refeshing  and  invigorating  effect  of  pure  (unbaked)  cold  air, 
he  placed  cases  on  the  fire-escape,  where  it  was  so  cold  that  the  spu- 
tum froze. 

The  patient's  face  and  head  may  be  protected,  if  need  be,  with  the 
exception  of  the  nose  and  mouth.  It  is  my  custom  to  examine  at  each 
visit  the  aeration  of  the  sick-room,  and  to  administer  the  most  strin- 
gent rebuke  to  the  nurses  and  friends  if  it  be  neglected. 

As  in  typhoid  fever,  the  diet  should  be  restricted  to  milk  and 
farinaceous  broths,  administered  with  precision  while  the  patient  is 
awake,  every  two  hours,  in  quantities  ranging  from  four  to  eight 
ounces.  I  do  not  share  the  horror  of  asthenia  in  this  disease,  which  is 
only  too  prevalent  and  leads  to  undue  feeding  and  stimulation.  The 
disease  is  of  short  duration ;  it  not  infrequently  suddenly  attacks  well- 
nourished  persons  in  the  midst  of  comparatively  good  health.  It  seems 
an  unphysiological  proceeding  to  stuff  these  patients  with  concentrated 
foods  in  large  quantities,  which  they  cannot  assimilate,  and  thus  to 
impose  an  additional  tax  upon  the  system.  Stimulants  also  have  rarely 
been  as  necessary  to  the  same  extent  as  formerly,  since  the  course  of 
management  here  outlined  was  adopted.  In  the  case  of  alcoholic  sub- 
jects whose  consumption  of  liquor  has  been  a  daily  habit  and  require- 
ment, one-half  to  two  ounces  of  good  whiskey  every  two  or  three  hours 
may  be  useful,  especially  while  resolution  is  going  on,  but  not  as  a  spur 
to  a  failing  heart,  as  is  commonly  the  purpose.  Not  quite  sure  on  this 
point,  I  still  feel  myself  under  the  dominion  of  this  idea.  It  would 
seem  that,  inasmuch  as  a  large  part  of  alcohol  is  eliminated  through 
the  lungs,  the  latter  are  needlessly  overburdened  while  they  are  strain- 
ing their  functionary  capacity  to  the  utmost. 

Of  medicinal  agents  but  very  few  are  required.  Besides  an  open- 
ing dose  of  ten  or  fifteen  grains  of  calomel  given  dry  on  the  tongue 
and  washed  down  by  a  drink  of  water,  strychnine,  and  an  occasional 
dose  of  morphine  for  pain  are  the  only  medicines  that  seem  to  be  of 
any  real  value.  When  the  first  sound  of  the  heart  becomes  muffled  or 
feeble,  which  rarely  happens  if  hydrotherapy  is  applied  early,  hypo- 
dermics of  strychnine,  one-thirtieth  to  one-tenth  of  a  grain  every  three 
or  four  hours,  offer  a  valuable  aid  to  tide  the  patient  over  a  trying 


PNEUMONIA.  349 

period.  Given  even  to  the  production  of  trismus,  if  necessary,  strych- 
nine is  far  superior  to  digitalis  or  brandy.  An  occasional  dose  of  phe- 
nacetin  or  other  antipyretic  may  be  resorted  to  when  the  patient  is 
restless  with  high  temperature,  but  its  use  should  not  become  a  routine 
practice  for  temperature  reduction  ;  it  is  rarely  required.  Quinine, 
aconite,  veratrum,  digitalis,  and  other  drugs  I  have  discarded,  after  a 
prolonged  trial. 

The  most  valuable  remedy  in  pneumonia  is  hydrotherapy  judiciously 
adapted  to  the  indications  of  the  case.  Its  application  will  be  consid- 
ered under  two  heads,  viz. :  1.  Pneumonia  of  children.  2.  Pneu- 
monia of  adults. 

1.  PNEUMONIA  OF  CHILDREN. 

Although  the  principles  underlying  a  correct  application  of  water 
in  pneumonia  are,  as  in  other  diseases,  the  same  in  children  and  in 
adult  life,  the  former  present  certain  peculiarities  which  it  may  be  in- 
teresting and  profitable  to  discuss.  The  sensitive  nervous  organization 
of  the  child  endows  it  with  greater  susceptibility  to  the  development 
of  nervous  symptoms.  Convulsions  not  infrequently  occur  in  pneu- 
monia; delirium  and  jactitation,  listlessness,  and  somnolence  ofteii 
characterize  it  in  children. 

The  toxic  agents  circulating  in  the  blood  in  pneumonia  do  not 
endow  the  heat  centres  with  the  same  resisting  capacity  to  heat  reduc- 
tion by  hydriatric  cooling  measures  as  in  typhoid  fever.  This  empiri- 
cal fact  upon  which  I  have  based  the  diagnostic  bath  (page  322)  is  em- 
phasized in  the  child  by  reason  of  the  larger  surface  area  in  the  child 
in  proportion  to  its  weight,  which  favors  a  more  rapid  cooling  of  the 
body  of  the  child  than  of  that  of  an  adult.  Moreover,  the  heart  of 
the  average  child  does  not  possess  the  resisting  power  of  the  adult 
heart,  and  therefore  the  sudden  contraction  of  the  proportionately 
larger  area  of  cutaneous  vessels  by  intense  cold  may  induce  collapse 
more  readily  in  the  child  than  in  the  adult  if  prolonged.  This  fact 
must  be  constantly  borne  in  mind  in  the  prescription  of  hydriatric  pro- 
cedures, by  the  correct  adaptation  of  which  danger  may  not  only  be 
obviated,  but  may  be  fully  and  successfully  met,  with  the  result  of 
promoting  rapid  recovery  and  saving  life. 

In  pneumonia  as  in  other  infectious  diseases  the  chief  danger  is 
not  to  be  sought,  as  I  have  often  pointed  out,  in  the  high  temperature. 
The  heart  is  more  threatened  in  this  disease  than  in  any  other,  be- 
cause, in  addition  to  its  depreciation  by  the  toxaemia,  the  obstructed 
pulmonary  circulation  increases  the  amount  of  work  it  is  called  upon 
to  do,  and  thus  contributes  an  additional^element  of  danger. 

In  the  early  stages  of  pneumonia  in  children  the  full  bath  is  ex- 


350       THE   PRINCIPLES   AND   PRACTICE   OF  HYDROTHERAPY. 

tremely  useful.  Children  are  so  easily  handled  and  many  are  so  accus- 
tomed to  bathing,  that  this  procedure,  carefully  adapted,  produces  a  min- 
imum of  disturbance  with  a  maximum  of  effect.  It  is  always  wise  to 
begin  bathing  when  the  body  temperature  reaches  103°,  although  a  lower 
temperature  also  demands  the  bath  when  nervous  symptoms  are  pro- 
nounced. Beginning  with  a  friction  bath  of  95°  for  eight  minutes,  this 
should  be  repeated  every  four  hours,  and  its  temperature  reduced  two 
degrees  each  time  and  its  duration  prolonged  to  ten  or  twelve  minutes 
if  reaction  and  refreshment  ensue.  I  do  not  resort  to  full  baths  below 
80°  in  the  pneumonia  of  children,  for  reasons  stated  above.  Friction 
must  never  be  omitted ;  chilling  which  is  apt  to  occur  in  children, 
may  alarm  the  parents  and  lead  to  a  subsequent  rise  of  temperature. 
Such  baths  usually  reduce  the  temperature  two  or  three  degrees;  they 
stimulate  the  heart,  deepen  the  inspiration,  promote  expectoration, 
and  refresh  the  child,  as  no  medicinal  agent  is  capable  of  doing.  Their 
effect  may  be  prolonged  by  chest  compresses  (page  142),  repeated 
every  hour  or  two  as  required.  When  dyspnoea,  heart  failure,  cya- 
nosis, delirium,  or  other  alarming  manifestations  occur,  a  briefer  but 
more  energetic  procedure  is  indicated.  The  little  one  is  held  for  five 
minutes  in  a  bath  of  100°  up  to  its  navel,  and  two  or  four  basins  of 
water  at  75-65°  are  poured  over  its  shoulders  rapidly.  This  should  be 
followed  by  rapid  friction  and  drying.  This  procedure  may  be  repeated 
every  two  or  four  hours,  as  indicated.  The  result  is  simply  delightful. 
Crying  and  coughing  which  naturally  ensue,  aid  in  expectoration  of 
stagnant  secretions ;  the  respiration  is  rendered  free  and  unobstructed ; 
the  skin  grows  red  and  congested,  relieving  the  heart  most  admirably 
when  combined  with  the  reflex  stimulation  of  the  organ  produced  by 
the  brief  but  sudden  impact  of  cold.  The  pulse  becomes  less  frequent, 
more  quiet,  and  regular.  The  pulmonary  circulation  being  improved, 
a  local  effect  upon  the  inflamed  and  congested  parenchyma  is  produced. 

This  method  of  treatment,  combined  with  the  usual  hygienic  and 
dietetic  management,  has  afforded  the  author  satisfactory  results  not 
only  in  family  practice  but  also  in  the  large  clinical  material  of  the  New 
York  Juvenile  Asylum,  which  was  at  his  disposal  for  thirteen  years. 

The  value  of  hydrotherapy  in  the  pneumonia  of  children  has  been 
confirmed  by  the  highest  authorities.  Jacobi*  "  uses  cold  baths  or  packs 
when  the  temperature  is  high,  but  most  cases  will  do  quite  well  with 
sponging  or  friction  with  wet  and  cold  towels.  The  latter  plan  acts 
both  as  a  refrigerant  and  stimulant." 

It  is  not  "the  cooling  of  the  surface,"  however,  which  is  the  key 
to  the  rationale  of  the  cold  bath,  but  the  stimulus  following  the  shock, 
due  to  impingement  of  cold  upon  the  cutaneous  nerves,  which  is 

*  Archives  of  Pediatrics.  1895. 


PNEUMONIA.  351 

conveyed  to  the  central  nervous  system  and  thence  reflected  to  every 
organ  over  which  it  presides.  The  cooling  (refrigerant)  effect  is  the 
most  palpable  to  the  eye;  it  is  demonstrated  by  the  thermometer;  but 
if  this  were  the  chief  aim  of  pneumonia  therapy  it  would  be  far  more 
perfectly  reached  by  the  coal-tar  antipyretics. 

Jacobi  correctly  says :  "  It  is  not  the  temperature  that  is  injurious, 
but  the  absence  or  insufficiency  of  resistance  the  tissues  offer  to  its 
effect." 

The  danger  lies  in  the  toxaemia  which  is  overwhelming  the  nervous 
system,  and  thus  impairing  the  functions  of  the  organs  depending  upon 
them;  digestion,  respiration,  cardiac  action,  the  secretions,  all  are 
crushed  under  the  octopus,  infection.  The  system  is  laboring  under 
the  load;  the  conservative  powers  residing  within  it  are  strained  to 
their  utmost  to  maintain  life.  The  cold  bath  comes  nobly  to  the 
rescue,  when  judiciously  used;  the  nervous  system  is  refreshed,  the 
dormant  functions  are  aroused  to  renewed  activity,  the  eye  brightens, 
the  respiration  is  deepened,  the  pulse  is  slowed  and  rendered  less 
dicrotic.  But  this  effect  is  not  produced  by  the  antipyretic  bath, 
which  allows  the  patient  to  lie  quietly  in  the  cold  water,  and  from  which 
he  is  taken  when  he  shivers.  Active  but  gentle  friction  of  the  surface 
prevents  chilling  and  multiplies  the  shock  to  the  peripheral  nerves, 
while  it  counteracts  paresis  of  the  vascular  walls  and  formation  of 
cutis  anserina.  Such  a  bath  is  antifebrile,  meeting  all  indications  aris- 
ing from  insufficiency  or  absence  of  resistance. 

A.  Baginsky  *  teaches  that  "  the  chief  aim  is  to  moderate  fever  and 
maintain  the  strength.  Both  indications  are  well  fulfilled  by  cold  com- 
presses around  the  thorax,  repeated  every  half-hour  or  hour.  When 
properly  employed  under  appropriate  conditions,  especially  w:'.th  regard 
to  cardiac  power,  they  may  be  life-saving,  and  they  are  to  be  decidedly 
preferred  to  antipyretics,  which  are  to  be  avoided  in  the  pneumonia 
of  children,  because  of  their  deleterious  effects  upon  the  heart." 

Professor  Penzoldt  f  gives  an  analysis  of  twenty -two  hundred 
cases  treated  from  1867  to  1889  in  the  Poliklinik  of  Erlangen.  "  The 
reduction  of  temperature  is  not  to  be  regarded  the  sole  factor.  If  the 
indication  is  to  improve  the  respiration,  circulation,  and  cerebral  activ- 
ity, and  to  further  expectoration,  preference  should  always  be  given  to 
a  cautious  bath  treatment. " 

Professor  Hutinel,  in  a  clinical  lecture  at  the  Hopital  des  Enfants 
Malades,  J  closely  presents  the  view  I  have  so  often  urged :  "  It  is  espe- 
cially against  the  different  manifestations  of  the  general  infection  that 

*"Lehrbuch  der  Kinderkrankheiten, "  1896. 

t  Miinchener  Medicinische  Wochenschrift,  1890,  No.  36. 

t  Le  Bulletin  Medical,  Paris.  1893. 


352        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

we  must  act;  and  it  is  precisely  in  those  cases  in  which  the  general 
phenomena,are  quite  marked  that  cold  baths  (64°  to  75°  F.)  are  par- 
ticularly useful.  The  cold  bath  not  only  diminishes  the  temperature 
of  the  body ;  it  at  the  same  time  exercises  other  beneficial  influences. 
It  enhances  the  various  secretions,  increases  the  arterial  pressure,  and 
sustains  the  heart ;  while,  on  the  other  hand,  most  of  the  antithermic 
remedies  produce  untoward  effects  in  similar  conditions. 

"  The  cold  bath  acts  energetically  upon  the  nervous  system.  It 
gives,  as  Professor  Peter  has  remarked,  speaking  of  typhoid  fever,  a 
lashing  to  the  economy.  It  diminishes  the  depression  so  marked  in 
certain  cases  of  broncho-pneumonia.  Patients  who  have  been  bathed 
return  to  life,  to  use  the  happy  expression  of  Juhel-Kenoy.  In  my 
experience  the  cold  bath  has  never  produced  evil  effects  upon  the  lung, 
and,  like  many  others,  I  am  convinced  that  the  measure  has  been 
wrongly  accused  of  being  the  cause  of  pulmonary  complication." 

Hutinel  details  a  desperate  case  as  a  striking  illustration  of  the 
water  treatment  of  pneumonia,  and  he  affords  us  a  glimpse  of  his 
practical  ability  as  follows :  "  Families  will  often  oppose  the  applica- 
tion of  a  cold  bath  in  these  cases.  Under  such  circumstances  we  must 
employ  a  certain  amount  of  artifice.  Under  the  cover  of  revulsion  you 
may  add  to  the  water  a  little  mustard ;  for,  as  a  general  rule,  parents 
believe  in  the  efficacy  of  this  simple  remedy,  and  it  behooves  us  to 
wrestle  not  so  much  against  their  reluctance  as  against  their  overzeal- 
ousness.  At  the  Hospice  des  Enfants  Assistes  I  have  obtained  most 
excellent  results,  but  I  have  also  observed  many  failures.  Employed 
when  specially  indicated,  cold  baths  produce  excellent  results ;  but  em- 
ployed indiscriminately,  they  are  often  the  source  of  disappointment. " 

M.  Albert*  reports  forty  cases  of  broncho-pneumonia  of  children 
from  four  months  to  four  years  old,  which  he  treated  with  half-hourly 
or  hourly  chest  compresses  dipped  in  water  of  59°-68°;  the  mortal- 
ity was  seventeen  per  cent. 

Le  Gendre  f  states  "  in  the  course  of  all  acute  diseases  of  the 
respiratory  passages  and  in  certain  acute  stages  of  chronic  disease  of 
the  same  region,  active  hypersemia  is  an  important  factor  in  determin- 
ing the  aggravation  of  the  local  and  general  conditions.  In  cases  where 
such  hyperaemia  occurs  I  have  found  preferable  to  all  other  revulsive 
measures  the  permanent  wrapping  of  the  thorax  in  compresses  soaked 
in  cold  water,  wrung  out  so  as  to  be  merely  damp,  and  covered  with  a 
thin  oilcloth.  These  compresses  should  be  renewed  every  quarter  of 
an  hour,  then  every  half-hour  or  hour,  according  to  the  condition  of 
the  patient.  This  method  is  of  especial  value  in  infantile  therapeutics ; 

*  Gazette  Hebdomadaire,  88,  1896. 

t  La  Medecine  Moderue,  March,  17th,  1894. 


PNEUMONIA.  353 

it  may  be  used  for  the  youngest  child,  continued  as  long  as  necessary, 
and  resumed  whenever  there  is  a  return  of  the  congestion." 

In  the  discussion  of  Le  Gendre's  paper  Rendu  stated  that  he  had 
made  use  of  the  wet  pack  since  1884,  and  had  found  that  it  caused 
great  improvement  in  grave  broncho-pneumonia.  He  does  not  use  the 
same  method  as  Le  Gendre,  but  leaves  his  patient  in  the  pack  for  two 
or  three  hours.  Richardiere  has  treated  sixty  cases  of  broncho-pneu- 
monia after  measles  at  the  Trousseau  Hospital,  and  has  had  excellent 
results  with  the  wet  pack.  An  important  fact  is  that  the  temperature 
does  not  immediately  fall,  but  that  the  nervous  phenomena  are  quieted 
and  abundant  sweating  occurs. 

2.  PNEUMONIA  OF  ADULTS. 

Although  the  analogy  between  pneumonia  and  typhoid  fever,  as 
stated  above,  is  marked,  the  author  refrains  from  the  cold  friction  bath 
in  this  disease  for  reasons  stated  below. 

Pneumonia  occurring  in  adults  has  long  been  treated  by  Jurgensen 
and  others  with  cold  baths  of  60°-70°,  of  ten  to  fifteen  minutes'  dura- 
tion, and  large  quantities  of  stimulants  to  counteract  heart  failure. 

Dr.  A.  Vogl,  chief  of  military  hospitals  in  Munich,  has  in  a  written 
communication  informed  me  that  he  has  found  the  baths,  as  applied  in 
typhoid  fever,  of  great  value  in  pneumonia.  Being  a  very  careful  and 
conscientious  clinician,  however,  he  was  unwilling,  upon  the  strength 
of  only  a  few  hundred  cases,  to  furnish  practical  deductions. 

The  gentlemen  who  report  therapeutic  successes  from,  or  sweep- 
ingly  condemn  cold  baths  upon  results  derived  from  a  few  cases,  may 
here  draw  a  valuable  lesson  of  caution.  This  has  been  the  author's 
reason  for  withholding  in  this  work  his  own  experience  as  an  argument, 
wherever  larger  statistical  material  could  be  brought  to  bear  upon  the 
subject  from  other  sources. 

In  a  recent  address  before  the  Medical  Society  of  Munich,  Vogl  * 
gives  unequivocal  approval  to  the  friction  bath  precisely  as  used  in 
typhoid  fever  (Brand  method,  page  168),  because  the  therapeutics  of 
pneumonia,  aside  from  the  dietetic  management,  have  no  influence  on 
the  cause  of  the  disease  and  no  power  to  aid  the  failing  heart.  He 
claims  to  have  been  moved  to  the  adoption  of  the  friction  bath  in  pneu- 
monia by  its  reduction  of  mortality  in  typhoid  fever,  in  which  he  had 
so  often  seen  pneumonia  favorably  influenced  by  the  cold  friction  bath. 
In  this  disease,  as  in  the  former,  the  specific  effect  is  evoked  not 
against  the  disease,  but  for  the  protection  of  the  organism  against  the 
general  infection.  Vogl  prefers  to  base  his  claim  upon  the  easily  ob- 
served effect  of  these  baths  upon  the  circulation,  respiration,  and  inner- 

*Munchner  medicinische  Wochenschrift,  1902. 
23 


354       THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

ration,  rather  than  upon  statistics.  It  is  to  be  regretted  that  he  has 
omitted  the  latter,  because  he  has  furnished  the  only  convincing  statis- 
tics in  therapeutics  of  typhoid  fever.  The  patient  holds  his  breath 
involuntarily  upon  entering  the  bath,  but  soon  begins  to  inspire  deeply, 
and  to  expectorate;  interrupted  voice  and  cyanosis  diminish;  he 
breathes  freely  and  brightens  up  after  the  bath.  The  pulse  indicates 
how  much  the  heart  has  been  relieved.  Vogl  claims  that  the  relief  is 
so  great  that  when  it  ceases  the  patient  very  often  desires  a  repetition 
of  the  bath.  As  in  typhoid  fever,  he  advises  all  cases  reaching  103° 
F.  to  receive  the  friction  bath  if  no  organic  heart  disease,  arterial  scle- 
rosis, emphysema,  etc.,  contraindicate.  "Executed  in  this  manner, 
the  cold  bath  offers  absolutely  no  danger  to  the  pneumonia  patient,  I 
am  convinced."  The  positive  views  of  this  competent  and  judicious 
authority  deserve  careful  consideration. 

In  a  discussion  on  pneumonia  *  Dr.  Charles  B.  Folsom  stated  that 
he  had  tested  the  cold-bath  treatment  in  thirty-six  severe  cases  in  the 
Boston  City  Hospital.  He  was  more  than  satisfied  with  the  results. 
In  marked  contrast  with  the  bath  treatment  of  typhoid  fever  was  the 
fact  that  all  these  patients  said  that  the  baths  were  grateful  to  them. 
These  baths  controlled  the  fever,  diminished  the  cough,  lessened  de- 
lirium, and  induced  sleep. 

Dr.  Northrup,  physician  to  the  Presbyterian  Hospital,  said  "  that  a 
bath  of  90°  F.  would  often  calm  a  very  excitable  patient  with  an  alco- 
holic pneumonia,  and  would  at  the  same  time  improve  his  general  con- 
dition. He  had  proved  by  experience  the  benefits  of  hydrotherapy  in 
pneumonia,  and  believed  that  in  this  disease  the  effect  of  such  treat- 
ment could  be  briefly  summed  up  by  saying  that  it  quieted  the  mental 
excitement,  improved  the  quality  of  the  pulse,  increased  the  depth  of 
the  respirations,  and  promoted  sleep." 

Professor  Strumpell  t  advocates  tepid  baths  (90°-92.5°)  as  the  most 
effective  means  of  improving  the  respiration,  of  aiding  expectoration, 
and  of  stimulating  and  refreshing  the  whole  system.  "  The  main  point 
is  that  the  patient  should  make  no  physical  exertion  in  the  bath ;  that 
he  should  be  lifted  into  it,  held  and  supported  while  in  it,  and  lifted 
into  bed  again  after  it.  The  favorable  action  of  the  baths  is  especially 
seen  in  the  great  relief  and  refreshment  that  the  patient  feels.  The 
respiration  is  quieter  and  slower,  but  deeper;  the  patient  often  falls 
into  a  quiet  sleep  after  the  bath." 

My  observation  agrees  with  that  of  Strumpell,  that  the  disturb- 
ance and  agitation  incident  to  a  cold  tub  bath  increase  the  lung  dis- 
turbance. If  the  patient  is  very  dull,  cyanotic,  and  presents  great 

*  Medical  News,  January  3d,  1897. 
f"  Text-Book  of  Medicine,"  p.  205. 


PNEUMONIA.  355 

nerve  prostration,  resembling  the  typhoid  state,  I  do  not  hesitate  to, 
choose  between  the  two  evils,  an  increase  of  the  local  disturbance  and 
a  decrease  of  nerve  prostration,  by  placing  the  patient  into  a  bath  of 
80°  F.,  or  less,  or  seating  him  in  water  at  100°  and  pouring  several 
basins  of  water  at  65°-75°  F.  over  his  head  and  shoulders.  This 
has  been  referred  to  (page  333)  as  a  valuable  heart  tonic.  It  serves, 
by  deepening  the  inspirations,  to  dislodge  accumulations  in  the  bronchi, 
which  have  crippled  the  healthy  as  well  as  the  affected  lung. 

The  Chest  Compress. — In  my  own  observation  the  chest  compress 
has  proved  the  most  useful  hydriatric  procedure  in  pneumonia. 

The  technique  of  this  procedure  has  been  explained  on  page  142, 
with  a  detail  that  may  seem  needless,  but  these  details  insure  precision, 
and  upon  their  exact  execution  may  depend  success  or  failure.  The 
physician  should  himself  supervise  the  first  application,  just  as  he  should 
supervise  the  first  Brand  bath  in  typhoid  fever.  A  skilled  nurse  can 
apply  these  compresses  with  a  minimum  of  disturbance. 

There  is  need,  too,  of  individualization.  In  the  average  case  a 
temperature  of  60°  F.  will  be  appropriate.  Should  the  patient  evince 
stupor  or  muttering  delirium,  a  lower  temperature  should  be  adopted, 
and  the  chest  should  receive  one  or  more  dashes  of  colder  water  before 
renewal  of  each  compress.  The  same  procedure  is  useful  in  broncho- 
pneumonia,  when  the  bronchi  are  blocked  by  secretions  or  cyanosis 
exists.  In  a  case  which  I  had  the  privilege  of  seeing  with  Dr.  E.  J. 
Ware,  this  application  proved  its  worth.  By  skilful  management  the 
patient  had  been  sustained  up  to  this  time.  The  right  lung  in  its  entire 
posterior  aspect  was  solidified.  The  temperature  was  usually  below 
102°  F.,  and  the  pulse  exceedingly  rapid.  There  was  no  dyspnosa.  In 
this  case  the  modified  procedure  referred  to  was  extremely  valuable- 
Inspiration  soon  deepened,  the  heart  slowed,  and  in  a  few  days  the 
patient  rallied  from  a  most  desperate  condition. 

A  higher  temperature  than  60°  F.  may  be  used  if  there  be  much 
jactitation,  insomnia,  or  excitability.  In  the  latter  event  great  benefit 
will  accrue  from  allowing  the  compress  to  remain  two  hours  and 
moistening  it  more  thoroughly,  which  converts  the  compress  into  a 
soothing  fomentation  that  is  not  relaxing  like  a  poultice. 

In  a  colleague,  whom  I  had  the  privilege  of  seeing  with  Dr.  Palmer 
Cole,  there  was  complete  involvement  of  the  entire  right  and  sub- 
sequently of  the  left  lung,  with  temperature  ranging  from  103°-105° 
F.,  the  heart  action  being  fair.  The  patient  being  a  morphine  habitue, 
there  was  a  decided  neurotic  element  in  the  case,  involving  insomnia 
and  great  jactitation.  The  compresses  were  applied  hourly,  despite 
the  high  temperature,  but  they  were  allowed  to  be  quite  moist,  in  order 


356        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

to  obtain  a  calming  effect.  Dr.  Cole  says :  *  "  The  patient  has  uo 
recollection  of  what  had  occurred  during  a  period  of  four  weeks.  He 
subsequently  thanked  me  more  for  having  cured  him  of  his  opium 
habit  than  for  saving  his  life.  I  have  not  the  slightest  doubt  that  the 
patient  owed  his  life  to  the  persistent  external  use  of  cold  water,  and 
that  under  any  other  treatment  he  would  have  died." 

Rationale  of  the  Cold  Compress  in  Pneumonia. — No  remedial 
measure  deserves  adoption  by  the  profession  unless  the  rationale  can 
be  satisfactorily  explained.  Besides  the  usual  effect  of  applications 
greatly  below  the  temperature  of  the  skin,  there  is  added  probably  a 
direct  reflex  effect  upon  the  pulmonary  circulation,  arising  from  the 
relation  of  the  nerve  supply  of  the  cutaneous  covering  of  the  chest 
walls  to  the  cerebro-spinal  centres.  Recent  experiments!  have  shown 
that  the  pulmonary  vessels  are  supplied  by  vasomotor  nerves  through 
the  roots  of  the  second  to  the  seventh  dorsal  nerves.  The  scapular 
reflex  area,  which  lies  in  the  skin  between  the  scapulae,  is  connected 
with  the  first  three  dorsal  ganglia,  while  the  "  epigastric  reflex,"  which 
resides  in  the  skin  of  the  epigastrium  and  sides  of  the  chest,  is  con- 
nected with  the  fourth,  fifth,  sixth,  and  seventh  dorsal  ganglia. 
Hence  a  positive  effect  upon  the  vasomotor  supply  of  the  lung  may 
be  evoked  by  covering  the  entire  chest,  to  a  line  with  the  umbilicus, 
with  a  compress  more  or  less  wrung  out  of  water  forty  to  fifty  degrees 
below  the  temperature  of  the  skin. 

The  therapeutic  indications  are — (1)  to  stimulate  and  refresh  the 
nerve  centres  with  a  view  to  enhancing  the  patient's  vital  powers;  (2) 
to  prevent  and  control  heart  failure  ;  (3)  to  reduce  temperature  ;  (4) 
to  eliminate  toxins. 

The  nerve  centres  are  well  stimulated  and  rehabilitated  by  the  re- 
peated gentle  shocks  and  subsequent  reactive  stimulation  of  the  sensory 
fibres  in  the  skin,  both  of  which  are  conveyed  to  the  central  nervous 
system  and  thence  reflected  to  the  organs,  upon  whose  functionating 
capacity  depends  the  patient's  ability  to  resist  the  toxic  agencies 
circulating  in  the  blood.  We  aim  here  to  accomplish  precisely  the 
same  object  as  with  the  Brand  bath  in  typhoid  fever.  The  milder 
form  of  "  shock  "  is  better  adapted  to  pneumonia  because  it  is  less  dis- 
turbing, and  because  the  toxaemia  induced  by  the  diplococcus  is  less 
intense  in  the  average  case,  and  certainly  has  only  one-third  that  of 
the  life  period  of  the  Eberth  bacillus. 

After  a  few  compresses  the  patient  grows  more  calm,  the  inspira- 
tions, which  are  deepened  by  each  application,  continue  deeper,  dysp- 
noea is  markedly  relieved,  sleep  ensues,  appetite  improves,  and  the 

*  Medical  News,  February  19th,  1898. 

f  "Text-Book  of  Human  Physiology,"  Landois  and  Stirling,  vol.  i.,  p.  149. 


PNEUMONIA.  357 

skin  and  kidneys  begin  to  act  more  freely.  These  clinical  evidences 
demonstrate  the  correctness  of  the  rationale  enunciated  above. 

The  maintenance  of  the  heart  action  is  accomplished  by  the  wet 
compresses  in  the  following  manner:  When  the  cold  compress  is 
applied,  there  is  a  rapid  contraction  of  the  cutaneous  vessels,  which 
raises  the  tension  at  once,  but  eventuates  in  a  tonic  dilatation  of  these 
vessels,  which  is  evidenced  by  a  ruddy  hue  of  the  skin.  This  dilata- 
tion differs  very  decidedly  from  that  relaxed  condition  of  the  cutaneous 
vessels  produced  by  warm  poultices.  The  latter  relax  the  vasocon- 
strictors, producing  a  paretic  condition  of  the  vessels,  or  a  stasis,  while 
cold  applications  stimulate  the  vasodilators,  giving  rise  to  an  active 
dilatation,  with  maintenance  of  the  tone  of  the  vessels,  an  active 
hypersemia,  by  reason  of  which  the  blood  is  propelled  more  vigorously 
through  them.  The  heart  is  thus  relieved;  not  by  a  vis  a  tergo,  as  is 
the  case  after  digitalis,  but  by  a  vis  a- f route,  formed  by  broadening  of 
the  blood  stream  in  the  cutaneous  capillaries,  whose  enhanced  tonicity 
aids  at  the  same  time  in  propelling  the  blood  onward.  Arterial  tension 
is  increased,  as  is  evidenced  by  the  better  filling  of  the  radial  arteries. 
The  right  heart  is  indirectly  aided  by  this  enhancement  of  the  general 
tone  in  the  vascular  apparatus,  and  may  thus  expend  more  force  upon 
the  pulmonary  circulation,  whose  vessels  contract  more  firmly  by  rea- 
son of  the  dilatation  of  the  superficial  vessels.  Moreover,  the  vaso- 
motor  control  of  the  entire  pulmonary  circulation  is,  as  stated  above, 
under  the  influence  of  the  effects  arising  from  the  "  reflex  areas " 
which  are  stimulated  by  the  thermic  excitation  from  cold. 

Komberg  has  by  injecting  Fraenkel's  diplococci  into  rabbits  recently 
confirmed  what  I  have  for  many  years  insisted  upon,  that  the  heart  is 
embarrassed  by  reason  of  the  incompetent  peripheral  circulation  in 
infectious  diseases.  The  dyspnoea  and  overloading  of  the  right  ven- 
tricle are  not  due  chiefly  to  lung  infiltration,  because  when  crisis  ensues 
the  exudation  is  not  at  once  removed,  and  yet  the  respiration  and  circu- 
lation are  relieved  at  once.  This  can  be  accounted  for  only  by  the 
sudden  relief  of  the  nervous  system  from  toxic  elements  generated  by 
the  diplococcus,  whose  activity  ceases  at  once  when  it  has  reached  the 
end  of  its  natural  life  period.  It  is  probable  that  crisis  ensues  when 
the  antitoxins  evolved  in  the  natural  course  of  the  disease  have  attained 
an  overbalance  of  power.  The  battle  between  the  diplococcus,  with  its 
allies,  and  the  patient's  vital  powers,  is  at  an  end.  The  most  impor- 
tant effect  of  cold  applications  in  pneumonia  is,  therefore,  the  aid  and 
sustenance  they  furnish  to  the  nervous  system,  which  bears  the  brunt  of 
the  fight.  The  improvement  of  cardiac  action  is  one  of  the  results. 

Reduction  of  temperature  is  an  important  therapeutic  element  in 
these  cases.  Persistent  high  temperature  may  enfeeble  the  heart,  and 


358        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHEEAPY. 

certainly  depreciates  the  nerve  centres.  Some  good  clinicians  claim 
that  high  temperature  is  the  chief  danger  to  patients  suffering  from 
pneumonia.  Since  my  argument  against  this  view  *  I  have  repeatedly 
expressed  opposition  to  this  firmly  established  error,  an  error  which 
has  given  unhappy  prominence  to  the  coal-tar  antipyretics  in  the 
therapy  of  fevers.  If  any  further  testimony  is  needed  to  lay  this 
ghost,  which  has  so  long  affrighted  timid  practitioners,  to  rest,  the 
statements  of  Hutinel,  Baginsky,  and  Striimpell,  cited  above,  demon- 
strate that  we  should  cease  to  regard  elevation  of  temperature  as  the 
cardinal  symptom  for  therapeutic  attack  in  pneumonia.  While,  how- 
ever, these  clinicians  fully  corroborate  my  own  views  expressed  eight 
years  ago,  I  may  say  that  high  temperature,  though  not  actually  and 
directly  a  lethal  factor  by  inducing  fatty  degeneration  of  the  cardiac 
muscular  fibre,  does  seriously  cripple  the  work  of  the  heart  by  impos- 
ing upon  it  more  rapid  action,  and  it  does  seriously  interfere  with  the 
patient's  comfort.  High  temperature,  therefore,  demands  cartful  atten- 
tion by  measures  that  are  not  harmful  like  the  routine  use  of  coal-tar 
antipyretics.  I  do  not  hesitate  to  use  the  latter  occasionally  when  high 
temperature  is  associated  with  sleeplessness  or  great  jactitation.  They 
give  great  comfort  to  the  patient,  but  they  should  be  employed  only 
once  in  twenty-four  hours. 

The  susceptibility  of  pneumonia  patients  to  temperature  reduction, 
and  the  great  facility  with  which  the  temperature  may  be  reduced, 
render  great  care  in  the  application  of  these  measures  imperative.  For 
this  reason  /  have  abandoned  cold  baths,  and  have  dwelt  so  minutely 
upon  another  hydriatric  method.  That  so  mild  a  procedure  as  the  wet 
compress  should  be  capable  of  reducing  high  temperature  in  pneumonia 
I  have  numerous  charts  to  demonstrate.  The  decline  is  not  so  rapid  as 
after  cold  baths,  but  it  is  pronounced  and  steady.  It  does  not  ensue 
after  one  or  more  compresses,  nor  does  it  follow  the  course  of  temperature 
reduction  observed  after  cold  baths  in  typhoid  fever.  The  temperature 
decreases  day  by  day  one  or  more  degrees.  This  is  not  the  result  of 
direct  refrigeration;  such  an  effect  is  neither  aimed  at  nor  obtainable. 
When  a  compress  at  60°  F.  covered  with  flannel  is  applied  around  the 
chest  of  a  pneumonia  patient  who  presents  a  temperature  of  102°  to 
106°  F.,  there  is  an  immediate  cooling  of t the  surface  covered  by  it,  which 
is  followed  by  a  gradual  reaction  with  a  more  or  less  rapid  rise  of  the 
surface  temperature,  until  the  latter  is  nearly  the  same  as  it  was  pre- 
vious to  the  application.  The  surface  is  now  bathed  in  a  vapor  pro- 
duced by  the  heating  of  the  compress.  If  the  latter  be  allowed  to  re- 
main sufficiently  long,  the  flannel  covering  receives  the  vaporized  water, 
and  slowly  passes  it  outward  until  the  compress  becomes  dry.  But  if 
*  Transactions  of  the  New  York  State  Medical  Society,  1889. 


PNEUMONIA.  359 

the  compress  is  changed,  as  indicated  above,  the  vapor  is  more  slowly 
removed,  and  the  skin  and  compress  are  found  to  be  cooler  than  is  the 
flannel  covering.  Thus  the  gradual  cooling  process  is  continued  until  a 
fresh  cold  compress  is  applied,  when  the  skin,  more  sensitive  by  rea- 
son of  having  been  bathed  in  this  warm  vapor,  feels  the  "  shock  "  more 
distinctly  and  reacts  more  fully.  The  error  is  not  infrequently  com- 
mitted of  covering  a  wet  compress  with  oiled  silk.  While  this  would 
protect  the  bed  and  clothing  of  the  patient,  it  would  defeat  the  object 
of  the  compress  by  converting  it  into  a  poultice.  If  the  body  tempera- 
ture is  103°  F.  or  over,  the  compress  applied  as  above  becomes  warm 
in  half  an  hour,  although  evaporation  of  the  moisture  through  the  flan- 
nel renders  the  skin  under  it  cooler  than  other  parts  of  the  body. 
When  it  is  renewed,  the  repetition  of  the  gentle  shock  and  tonic 
dilatation  occurs.  Thus  a  slow  cooling  process,  not  relaxing  or  in  any 
way  depreciating,  is  maintained,  which  gradually  lowers  the  general 
temperature,  calms  the  patient,  and  contributes  much  to  his  recovery. 

How  far  this  cutaneous  hypersemia  acts  as  a  revulsive,  it  ie>  impos- 
sible to  ascertain,  but  it  is  a  well-known  fact  that  such  superficial 
hypersemia  is  always  accompanied  by  contraction  of  the  blood-vessels 
in  the  deeper  underlying  parts.  Thus  may  a  favorable  effect  be  pro- 
duced also  upon  the  inflamed  lung  tissue,  and  its  circulation  be 
improved. 

3.  The  elimination  of  toxins  is  promoted  by  the  wet  compress,  as 
by  all  cold  hydriatric  procedures. 

This  antitoxic  eliminating  effect  is  increased  by  frequent  libations  of 
water.  It  is  my  custom  to  administer  in  pneumonia,  as  in  typhoid  fever, 
six  ounces  of  cold  water  every  two  hours,  alternating  with  the  same 
quantity  of  cold  milk,  night  and  day,  when  the  patient  is  awake.  The 
enormous  increase  of  urine  is  scarcely  credible.  I  have  charts  showing 
from  sixty  to  one  hundred  and  twenty-two  ounces  in  twenty-four  hours. 

A  Peculiar  Effect. — There  is  a  striking  peculiarity  impressed  upon 
foe  regular  course  of  croupous  pneumonia  by  the  method  here  outlined, 
to  which  I  desire  to  call  attention.  Although  the  fever,  dyspnosa,  and 
other  distressing  manifestations  yield,  to  a  remarkable  extent,  in  a 
large  proportion  of  cases,  in  a  few  days,  the  physical  signs  do  not 
change  in  a  proportionate  degree.  Indeed,  I  have  observed  a  distinct 
crisis  in  only  about  forty  per  cent  of  the  cases  so  treated;  in  the 
remainder,  the  disease  ended  by  lysis  of  a  very  slow  type.  Improve- 
ment of  the  general  symptoms  goes  on,  the  patient  seems  well,  and  is 
anxious  to  rise,  but  a  dull  percussion  note,  muffled  breath  sounds,  and 
bronchial  whisper  bear  testimony  to  lingering  exudates  for  many  days, 
despite  normal  temperature.  When  the  latter  exists  in  the  afternoon 
I  allow  the  patient  to  rise,  as  was  illustrated  in  the  following  case. 


360       THE   PRINCIPLES   AND   PRACTICE   OF   HYDKOTHERAPY. 

H.  E ,  sickened  on  December  8th,  1895.     His  temperature  ranged  from 

102°  to  104°  F.  for  four  days,  without  any  pronounced  physical  signs  in  the 
lungs,  which  were  examined  every  day.  On  December  12th,  consolidation  of 
the  posterior  lower  half  of  the  right  lung  was  made  out.  The  mouth  tem- 
perature was  104°  F.  at  3  P.M.  ;  cough  had  been  distressing  several  days;  there 
were  now  rusty  sputum  and  increased  dyspnoea.  The  family  being  greatly 
alarmed,  Dr.  A.  A.  Smith  was  called  in  consultation,  but  did  not  see  the  patient 
until  the  next  morning.  Calomel  having  been  administered,  the  wet  compresses 
were  applied,  with  the  effect  of  bringing  the  temperature  down  two  degrees 
in  five  hours,  and  producing  good  sleep.  After  twelve  compresses  the  tempera- 
ture was  101°  F.  at  8  A.M.  When  Dr.  Smith  saw  him  at  ten  o'clock  he  found 
him  so  comfortable  that  he  expressed  surprise  at  being  called,  and  concurred  in 
the  treatment.  Physical  signs  of  consolidation  were  distinct.  There  had  been 
no  other  treatment  except  five  drops  of  dilute  hydrochloric  acid  every  two  hours, 
followed  by  six  ounces  of  water  as  a  placebo.  Temperature  reached  the  normal 
point  once  every  day  for  two  days,  and  remained  normal  for  ten  days,  when  the 
patient  was  dismissed.  Physical  signs  continued  during  Dr.  Smith's  attendance, 
and  dulness  of  the  percussion  note  had  not  entirely  cleared  up  when  I  last  saw 
the  patient,  although  he  was  free  from  temperature,  had  a  good  appetite,  and 
was  able  to  sit  up. 

Clinical  results  confirm  the  rationale  of  this  treatment,  and  attest 
its  value.  A  quarter  of  a  century  ago  the  greatest  living  German 
clinician,  Professor  Niemeyer  said :  "  I  have  made  extensive  employ- 
ment of  cold  in  the  treatment  of  pneumonia,  and,  relying  upon  a  large 
number  of  very  favorable  results,  can  recommend  the  procedure.  In 
all  cases  I  cover  the  chest  of  the  patient,  and  the  affected  side  in  par- 
ticular, with  cloths  which  have  been  dipped  in  cold  water  and  well 
wrung  out.  ...  In  the  hospital  at  Prague,  every  pneumonia  is  treated 
with  cold  compresses,  and,  according  to  the  statement  of  Smoler,  it  is 
exceptional  for  a  patient  not  to  feel  material  relief  from  the  treatment." 

Why  has  a  treatment  which  had  received  high  commendation  by 
so  eminent  a  teacher  not  become  an  established  practice  in  a  disease 
which  so  often  baffles  the  physician  under  other  management? 

For  the  student  of  the  history  of  hydrotherapy  this  question  is  not 
difficult  to  answer.  Although  water  is  an  orthodox  remedy,  to  which 
Hippocrates  devoted  almost  an  entire  book,  and  although  it  has  been 
highly  commended  by  eminent  physicians  at  various  times,  it  has  not 
become  the  common  property  of  the  profession,  because  most  of  those 
who  taught  its  use  and  value  most  earnestly,  failed  to  give  definite  direc- 
tions for  its  application.  Niemeyer  illustrates  this  point.  He  simply 
advises  "  cloths  wrung  out  of  cold  water  to  be  applied  to  the  chest"  of 
the  pneumonic  patient.  The  temperature  of  the  water,  the  duration, 
technique,  frequency  of  repetition,  were  left  to  the  discretion  and  good 
or  bad  judgment  of  his  hearers  and  readers,  and  yet  these  are  far  more 
important  in  hydrotherapy  than  are  the  preparation,  time  of  adminis- 
tration, frequency,  etc.,  in  prescribing  medicinal  agents. 


PNEUMONIA.  361 

Just  as  Niemeyer  failed  to  create  a  permanent  following  for  the 
practice  which  he  so  highly  lauded,  so  has  another  justly  famous 
American  teacher  failed  to  impress  upon  the  profession  a  practice 
which  he  had  taught  in  1870,  as  follows:  "If  there  be  anything  I 
should  rely  on  in  pneumonia,  if  the  temperature  is  very  high,  it  is  cold 
water."  If  this  excellent  teacher  had  been  as  explicit  in  giving  tem- 
perature, duration,  etc.,  of  the  "cold-water  treatment,"  as  he  was  in 
giving  the  doses  of  the  medicines  he  advises,  the  valuable  lessons  he 
endeavored  to  inculcate  would  not  now  (twenty-eight  years  later)  require 
to  be  taught  anew ;  they  would  have  served  as  a  beacon  light  to  the 
vain  searcher  after  reliable  therapeutic  methods  in  this  fatal  disease. 

Statistical  evidence  to  prove  the  value  of  the  measures  here  advo- 
cated, or  of  any  other  method  of  managing  pneumonia  patients,  is 
indeed  very  difficult  to  produce.  The  type  of  the  disease  differs 
very  much;  in  private  practice  the  number  of  cases  is  too  meagre, 
and  observations  are  too  inaccurate  and  unreliable.  The  author  has 
not  lost  a  case  of  uncomplicated  croupous  pneumonia  in  private 
practice  since  the  adoption  of  the  management  of  patients  here 
outlined.  In  hospital  work  the  chief  element  of  success  with  this 
method,  viz.,  its  application  in  the  early  stages  of  pneumonia,  is  unfor- 
tunately absent.  Its  favorable  influence  upon  the  progress  of  the  dis- 
ease is  attested,  however,  by  the  statistics  of  one  hundred  and  fifty-six 
cases  in  the  J.  Hood  Wright  Memorial  (formerly  Manhattan  General) 
Hospital,  in  which  the  total  mortality  from  pneumonia  has  been  reduced 
one-half  since  the  method  here  advocated  has  been  adopted  by  the 
entire  staff;  while  in  the  cases  admitted  before  the  fifth  day  the  mor- 
tality has  been  twelve  per  cent  against  thirty-seven  per  cent  under  the 
formerly  prevailing  expectant  plan,  many  patients  being  badly  nour- 
ished or  addicted  to  alcohol.  These  cases  were  under  the  observation 
and  treatment  of  my  colleagues,  Drs.  Daniels  and  Knickerbocker,  and 
myself. 

Catarrhal  Pneumonia. — The  method  described  above  is,  with  slight 
modifications,  equally  favorable  in  catarrhal  pneumonia.  When  the 
latter  occurs  in  infants  or  children,  cold  affusions  are  more  frequently 
required  than  baths ;  in  adults  ablutions  of  the  chest  are  useful  adju- 
vants to  the  supporting  measures  usually  applied  in  these  cases. 

Ample  confirmation  of  the  value  of  the  chest  pack  in  pneumonia 
may  be  cited  from  the  literature  of  the  subject.  Jackson*  relates  his 
experience  with  it: 

"  In  order  to  obtain  the  effects  to  be  desired  in  this  treatment,  the 
cold  must  be  freely  applied  and  with  a  firm  hand,  until  the  effect  of  a 
reduction  of  temperature  and  arrest  of  symptoms  occurs. 
*  Therapeutic  Gazette,  1892 


362        THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

"The  treatment  is  grateful  to  the  patient.  It  can  be  managed 
without  incommoding  the  sufferer,  by  the  exercise  of  a  little  ingenuity. 
It  is  prompt  in  its  effects  for  good,  and  it  is  easily  applied. 

"  Under  the  usual  routine  treatment  of  poultices,  expectorants,  and 
whiskey,  I  can  quite  understand  Dr.  Osier's  view  as  to  the  non-efficiency 
of  treatment.  But  with  the  experience  of  the  free  use  of  cold,  in  the 
manner  herein  outlined,  and  in  view  of  the  etiological  considerations 
advanced,  I  feel  that  a  new  and  happier  era  is  dawning  in  the  treat- 
ment of  pneumonia." 

In  order  to  offer  the  reader  a  fair  and  unbiassed  review  of  other 
hydriatric  methods  recommended  by  reliable  clinical  observers  in  pneu- 
monia, the  following  abbreviated  statement  of  Dr.  Fenwick,  of  the 
London  Hospital,  is  cited.  In  the  London  Lancet  Fenwick  furnishes 
an  analysis  of  1,000  cases  of  pneumonia  treated  by  different  methods 
during  the  last  ten  years.  In  56  cases  treated  by  cold  sponging,  the 
mortality  was  13  per  cent.  The  "  ice  cradle"  was  used  in  43  cases ; 
mortality  only  7  per  cent.  By  all  the  various  cold  applications  108 
cases  were  treated,  with  10  per  cent  of  failure.  By  all  other  grouped 
phases  of  treatment  the  losses  were  double  those  by  the  cold  method. 
Stimulants  were  given  in  these  latter  cases  whenever  indicated.  Cold 
appears  to  be  the  best  of  the  antipyretics  for  the  class  of  patients  with 
which  Dr.  Fenwick  has  to  deal,  chiefly  for  the  reason  that  it  has  less 
of  depressant  action  upon  the  heart  than  antipyrin,  quinine,  etc. 

The  aim  of  the  author  being  a  perfectly  fair  representation  of  the 
subject,  this  contribution  from  a  well-known  clinician  will  prove  valu- 
able in  moulding  opinion. 

Ice  Packs. — This  treatment  has  been  warmly  advocated  by  Dr.  T. 
J.  Mays,  of  Philadelphia,  who  brings  strong  statistical  testimony  to  its 
support.*  The  cases  cited  by  Dr.  Mays  are  the  result  of  a  collective 
report  from  general  practitioners  in  different  parts  of  the  United 
States.  Eighty-one  of  these  cases  are  reported  with  sufficient  detail 
to  enable  him  to  tabulate  them.  All  the  cases  in  this  table  bear  a 
record  of  the  sex  and  age  of  the  patient,  the  highest  temperature  and 
greatest  frequency  of  respiration  reached  during  the  attack,  the  number 
of  days  intervening  between  the  chill  or  the  beginning  of  the  disease 
and  the  day  of  crisis,  or  the  subsidence  of  fever;  the  presence  or 
absence  of  delirium,  the  unilateral  or  bilateral  location  of  the  disease, 
the  result  in  each  case,  together  with  remarks,  and  the  names  and 
addresses  of  the  reporters ;  they  are  chiefly  from  private  practice. 

The  ages  ranged  from  three  weeks  to  seventy-five  years ;  the  tem- 
perature from  100°  to  107°.  There  were  108  cases  of  single  and  38 
cases  of  double  pneumonia;  crisis  ranged  from  the  first  day  to  the 
twelfth  day  of  treatment. 

*Med.  Trans.,  Philadelphia  County  Med.  Soc.,  1895. 


PNEUMONIA.  363 

The  mortality  was  3.58  per  cent. 

Dr.  Mays  says  :  "  Cold  has  a  marked  and  decided  influence  on  the 
pneumonic  process,  not  only  in  bringing  it  to  a  favorable  termination, 
but  materially  to  shorten  its  course.  This  abortive  power  of  the  ice 
has  been  noticed  and  spoken  of  by  many  of  the  observers  in  my  collec- 
tion, and  I  believe  that  it  demonstrates  the  great  value  of  the  remedy 
more  than  anything  else." 

Dr.  C.  A.  Drew*  reports  favorable  results  from,  the  ice  treatment 
in  the  pneumonia  of  habitual  drunkards.  Under  the  routine  treatment 
the  mortality  in  61  cases  had  been  33  per  cent,  while  under  the  ice- 
bag  treatment  the  mortality  in  25  cases  was  4  per  cent.  He  states 
that  he  would  prefer  the  chest-compress  treatment  of  the  author  in 
cases  with  moderate  temperature  and  prominent  nervous  symptoms. 
In  cases  with  high  temperature  and  pain  he  applies  ice  bags  provided 
with  drainage  tubes  on  each  side  of  the  chest  over  the  thin  under 
flannel.  In  view,  of  the  extreme  fatality  of  pneumonia  in  drunk- 
ards, this  method  deserves  a  trial. 

While  the  statistical  evidence  of  the  ice-pack  treatment  is  very 
interesting,  I  cannot  accept  all  the  elements  of  the  rationale  offered 
by  Dr.  Mays  to  explain  its  favorable  action,  especially  the  direct  cool- 
ing effect  upon  the  lung.  It  would  seem  that  its  success  is  due  chiefly 
to  its  fulfilling  all  the  indications  in  pneumonia  almost  as  well  as  the 
chest  compresses.  The  ice  applied  in  bags,  which  are  wrapped  in 
towels  and  placed  over  the  affected  area,  cannot  reduce  the  inflam- 
matory process  in  the  lung  by  the  direct  effect  of  cold.  That  the  latter 
is  an  erroneous  idea  has  been  proven  by.  the  experiments  of  Silex  and 
Gilman  Thompson.  The  rationale  of  the  favorable  influence  of  the 
ice-compress  treatment,  however,  is  not  difficult  to  explain  upon  rec- 
ognized principles  of  hydrotherapy.  The  towels  which  envelop  the 
bags  of  ice  soon  become  thoroughly  wet  by  melting,  and  condensation 
on  the  outside  of  the  rubber  bag  dampens  the  under  vest;  thus  the 
ice  pack  becomes  practically  a  continuous  wet  compress,  with  the  dis- 
advantage that  complete  reaction,  which  is  so  useful  in  repeated  cold 
application  by  arousing  the  nerve  centres,  is  prevented.  Being  applied 
upon  parts  of  the  chest  only,  undesirable  results  are  prevented.  The 
objections  to  ice  compresses  would  seem  to  be  that  their  uneven  sur- 
faces render  them  uncomfortable  when  applied  to  the  posterior  por- 
tions of  the  lungs,  the  patient  lying  on  the  back;  and  that  their  weight 
when  applied  anteriorly  must  render  them  inconvenient.  In  considera- 
tion of  these  facts  I  have  not  felt  justified  in  applying  this  method  of  ice 
packs  so  long  as  good  results  were  obtained  from  the  wet  compresses. 

Experience  obtained  since  the  publication  of  the  second  edition 
*  Boston  Medical  and  Surgical  Jour.,  1907. 


364       THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

confirms  the  statements  made  above.  The  Medical  Record  of  Sep- 
tember 30th,  1905,  contains  the  following  results  of  my  observation : 

"  In  my  private  practice  the  exact  number  of  cases  treated  during 
the  past  twenty  years  is  not  available;  but  the  lowest  estimate  would 
probably  reach  one  hundred  cases.  The  mortuary  statistics  of  the 
New  York  Board  of  Health  will  show  that  I  have  reported  but  two 
deaths  from  pneumonia  during  the  past  twenty  years.  One  of  these 
was  an  alcoholic,  the  other  a  woman  to  whom  I  was  called  on  the  third 
day,  when  she  had  a  temperature  of  105°  F.,  and  the  incredible  num- 
ber of  forty  movements  from  a  large  self-administered  dose  of  Epsom 
salts.  She  survived  three  days.  That  my  cases  were  not  all  of  a  mild 
type  is  attested  by  the  fact  that  among  those  still  fresh  in  my  memory 
are  several  in  old  ladies  ;  one,  seen  with  Dr.  E.  H.  Rodgers,  was  a  dia- 
betic with  distinct  acetonuria,  suffering  from  influenza,  in  the  course  of 
which  both  lungs  were  successively  invaded.  Three  other  desperate 
cases  happen  to  be  remembered  because  they  occurred  in  colleagues. 
One  was  seen  with  Dr.  Palmer  Cole,  who  has  reported  the  case; 
another  with  Dr.  Ewing,  and  a  third  with  Dr.  Herff  in  San  Antonio, 
Texas,  where  I  happened  to  be  sojourning  for  a  few  days. 

"  It  is  unfortunate  that  few  physicians  preserve  the  records  of  acute 
cases,  in  order  to  afford  evidence  of  therapeutic  results  and  other  val- 
uable data.  In  cities,  however,  a  resort  to  the  Board  of  Health  statis- 
tics would  enable  us  to  reach  an  approximate  estimate  of  the  fatality 
in  our  cases  of  pneumonia." 

Confirmation  of  the  method  advocated  by  the  author  is  recorded  in 
Medizinische  Klinik,  No.  44,  1906,  in  an  article  on  the  treatment  of 
pneumonia  by  Staff-Surgeon  Paul  Schichhold,  of  Dresden,  who  re- 
ports on  two  hundred  cases  treated  by  "the  wet  vest "  which  is  a 
modification  of  the  author's  chest  compress  (see  description  on 
page  142).  He  applies  it  every  hour  practically  in  the  same 
manner,  using  a  blanket  instead  of  flannel  covering  for  the  com- 
press, wrung  out  of  water  at  55°  to  60°  F.  Schichhold  reports 
improvement  of  the  patients'  general  condition  in  nearly  all  the 
cases ;  respiration  became  more  free  and  deeper,  stitching  pains 
were  relieved,  the  patients  became  less  apathetic.  They  almost  in- 
variably liked  the  compress,  because  they  experienced  decided  relief. 
Expectoration  was  furthered.  Cardiac  activity  was  enhanced,  the 
pulse  became  more  regular  and  stronger.  Five  minutes  after  the  ap- 
plication of  the  cold  compress,  blood  pressure  (obtained  by  Gaertner's 
tonometer)  rose  15-20  mm.  Hg;  it  diminished  after  withdrawal  and 
increased  on  renewal  of  the  compress.  Mostly  the  pressure  did  not 
after  a  few  compresses  return  to  its  previous  low  level.  He  avoided 
medication,  except  in  very  serious  conditions  the  use  of  oxygen  in- 
halations. 


PNEUMONIA.  365 

The  temperature  reduction  was  very  remarkable,  and  did  not  con- 
sist, as  is  the  case  after  baths,  of  a  reduction  which  is  quickly  followed 
by  a  rise.  Temperature  remained  essentially  continuous  between  38.5° 
and  39.5°. 

Schichhold  has  observed  the  same  effect  of  this  treatment  upon  the 
crisis  as  the  author.  He  states  that  "  a  purely  critical  reduction  of 
temperature  is  far  more  rare  than  a  lysis;  both  occur  far  earlier,  some- 
times on  the  second  or  third  day.  It  was  an  immense  advantage  to 
the  patient  that  out  of  175  cases  131  had  no  crisis,  with  its  great  de- 
mand upon  the  heart.  Neither  involvement  of  the  other  luu-j  nor  of 
the  pleura  was  prevented." 

The  mortality  was  reduced  to  1.6  per  cent  (of  178  cases  treated 
with  the  wet  vest,  only  3  died),  1  of  these  the  result  of  cerebral  em- 
bolus,  and  another  complicated  with  old  valvular  thickenings. 

Schichhold  continues  to  apply  the  wet  vest  after  the  temperature 
has  become  normal.  His  experience  was  confined  to  soldiers  of  twenty 
to  twenty-five  years  with  few  exceptions  of  women,  and  children  over 
eight  years.  He  claims  that  this  treatment  is  without  result  in  ca- 
tarrhal,  bilious,  influenza,  and  streptococcus  pneumonia  and  unfavora- 
ble in  old  people  with  myocarditis  and  arteriosclerosis.  In  this  view 
the  author  can  not  coincide,  having  obtained  positive  amelioration  in 
such  conditions,  and  not  rarely  good  results  even  in  hospital  practice. 
As  in  typhoid  fever  the  results  of  hydriatric  measures  in  pneumonia  are 
influenced  favorably  by  early  application.  In  both  diseases  they  are 
not  curative  but  enhance  the  resisting  capacity  of  the  organism  and  in 
this  manner  prevent  lethal  conditions. 

Another  series  of  90  cases  reported  by  an  Austrian  military  sur- 
geon, Dr.  Nespor,*  was  treated  by  chest  compresses  and  cold  towel 
rubs  three  or  four  times  daily,  alternating  with  wet  chest  compresses. 
A  complete  record  of  90  cases  is  given  with  1  death. 

Summary. — In  conclusion  the  author  would  not  presume  to  regard 
the  method  here  advocated  as  an  ideal  one.  But  when  the  statistics 
of  a  hospital  f  receiving  the  worst  types  show  an  improvement  of  66  per 
cent  in  mortality,  and  a  military  hospital  with  exact  statistics  shows 
a  mortality  of  only  1. 6  per  cent,  and  private  practice  shows  a  reduc- 
tion to  2  per  cent,  the  author  may  regard  it  as  a  solemn  prerogative 
to  suggest  a  fair  trial  of  his  simple  method,  which  is  but  an  evolution 
of  all  methods  practised  by  him  during  forty-five  years,  including 
cupping,  blisters,  poultices,  cotton  jackets,  mercurialization,  antimony, 
veratrum  viride,  quinine,  opium,  antipyretics,  and  expectorant. 

*Blaetter  f.  klin.  Hydrotherapie,  January,  1903. 

f  These  statistics  were  carefully  gathered  by  the  house  surgeon,  Dr.  A.  J. 
Wittson,  who  became  my  successor  in  the  hospital  ten  years  later  and  continues 
this  method. 


CHAPTER  XVII. 

ENTERO-COLITIS. 

ENTERO-COLITIS  plays  havoc  among  children  whose  diet  and  hy- 
giene have  been  defective.  As  long  as  summer  diarrhoea  was  regarded 
as  a  purely  inflammatory  disease,  the  treatment  continued  unsatisfac- 
tory ;  the  mild  cases  recovered  and  the  more  severe  succumbed.  The 
prognosis  has  become  more  favorable  since  the  faulty  character 
of  this  theory  became  apparent,  and  since  the  substitution  of  hydri- 
atric  measures  for  the  formerly  prevalent  active  medicinal  treat- 
ment, together  with  more  careful  attention  to  the  removal  of  irri- 
tating matters  and  a  due  regard  to  food  and  other  hygienic  essentials. 
It  is  now  the  almost  universal  belief  that  this  disease  is  chiefly,  though 
not  solely,  due  to  the  ingestion  and  multiplication  of  micro-organisms 
which  create  in  the  gastro-intestinal  tract  conditions  somewhat  similar 
to  those  found  in  wounds  to  which  septic  material  has  had  access.  As 
in  the  latter  we  observe  heat,  redness,  and  swelling,  signifying  inflam- 
mation, with  all  its  concomitants  and  sequelae,  modified  by  the  posi- 
tion and  functions  of  the  parts  involved ;  so  have  we  in  the  former 
inflammations  whose  disturbing  influence  is  exerted  upon  the  organs 
involved,  and  which  give  rise  to  the  manifestations  of  so-called  entero- 
colitis. 

The  indications  of  treatment  are : 

1st.  To  diminish  or  remove  the  source  of  bacterial  supply. 

2d.  To  neutralize  the  disturbance  produced  by  the  bacteria. 

3d.  To  remove  them  from  the  intestinal  tract. 

4th.  To  meet  the  nervous  prostration,  inanition,  exhaustion,  and 
other  manifestations  due  to  the  diarrhoea. 

1st.  This  indication  exists  only  in  an  artificially  fed  infant.  A 
wet-nurse  should,  if  possible,  be  procured.  This  being  impossible,  it 
is  necessary  to  look  into  the  mode  of  preparing  the  food  supply,  i.  e. , 
pasteurizing  or  sterilizing  all  the  milk,  and  scrupulous  attention  to  its 
preparation  for  the  bottle,  are  of  the  utmost  importance.  All  these 
are  familiar  to  the  intelligent  physician. 

2.  To  neutralize  the  disturbance  produced  by  the  ingested  and 
multiplying  bacteria.  In  the  treatment  of  nausea  and  vomiting,  rest 
of  the  stomach  stands  first  and  foremost.  The  stomach  cannot  be  at 


ENTERO-COLITIS.  367 

rest  until  all  fermenting  material  be  removed  from  it.  This  may  be 
accomplished  by  the  copious  administration,  by  the  spoon  or  nursing- 
bottle,  of  warm  water,  to  which  a  small  quantity  of  saccharin  has  been 
added.  Irrigation  of  the  stomach,  by  means  of  a  soft-rubber  stomach 
tube  of  small  dimensions,  is  a  measure  of  the  greatest  value  (see  Tech~ 
nique,  page  250).  Every  physician  realizes  that  the  enforcement  of 
absolute  abstention  from  food  and  drink  in  the  early  stage  of  diarrhoea 
cannot  be  too  strongly  impressed  upon  the  mother.  It  will  require  all 
the  morale  she  possesses  to  execute  the  physician's  directions.  She 
may  be  convinced  by  the  argument  that,  since  everything  the  baby 
takes  is  rejected,  it  is  futile  to  continue  to  feed  it  or  even  give  it  water. 

3d.  To  remove  the  bacteria  from  the  intestinal  canal  is  the  leading 
indication.  It  is  important  that  all  fermenting  material  which  offers 
a  nidus  for  their  development  should  be  swept  out.  A  full  dose  of 
castor  oil,  or  when  the  stomach  is  irritable  a  dose  of  calomel,  will 
remove  the  entire  mass  from  the  upper  tract.  It  will  not  be  necessary 
to  repeat  the  purgative  if  it  is  followed  by  thorough  irrigation  of  the 
large  intestine  with  sterilized  warm  water. 

Experience  has  convinced  me  that  thorough  irrigation  of  the  large 
intestine,  administered  by  the  physician  or  by  a  competent  nurse 
under  special  instruction,  every  ten  or  twelve  hours,  lessens  the  num- 
ber and  changes  the  character  of  the  movements,  and  produces  a  most 
soothing  effect  upon  the  patient.  I  have  frequently  seen  infants  who 
had  been  tossing  in  pain,  purging  and  vomiting,  drop  into  gentle  slum- 
ber while  the  water  was  still  flowing.  Almost  invariably  a  quiet 
slumber  follows  the  irrigation,  the  purging  ceases  or  is  much  modified, 
and  the  whole  aspect  of  the  case  is  changed.  The  result  of  irrigation 
is  the  removal  of  bacteria,  mucus,  undigested  food,  and  fermenting 
material.  That  this  effect  is  feasible  is  evident  from  the  anatomical 
lesions.  The  lesions  in  summer  diarrhoea  are  most  frequently  found 
in  the  caecum,  sigmoid  flexure,  and  upper  part  of  the  rectum. 

Hence  we  may  safely  assume  that  the  irrigations  reach  the  diseased 
surface  in  most  instances.  Thus  we  follow  the  indications  of  modern 
therapeutics,  to  treat  local  troubles  by  local  measures,  as  far  as  possible. 
The  inflamed  parts  are  not  only  soothed  by  these  warm  irrigations,  but 
the  materies  morbi,  which  maintain  the  disease,  are  removed  and  neu- 
tralized in  the  most  thorough  manner. 

4th.  To  meet  the  manifestations  due  to  the  diarrhoea,  and  probably 
to  absorption  of  ptomains,  is  a  plain  indication.  Prostration  of  the 
vital  powers  is  often  rapid  and  pronounced,  threatening  a  speedy 
fatal  issue  in  many  cases,  from  the  very  inception  of  the  disease.  I 
confess  that,  until  recent  years,  the  true  cause  of  this  alarming  condi- 
tion escaped  me.  Since  the  recognition  of  high  body  temperature  from 


368       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

ptomain  poisoning,  and  of  this  toxaemia  as  the  chief  cause  of  the 
prostration,  the  prognosis  of  these  cases  has  become  far  more  favorable. 

An  elevated  temperature  range  frequently  marks  the  advent  of 
"  summer  diarrhoea, "  especially  of  the  more  alarming  types.  Indeed, 
if  the  rectal  temperature  were  more  systematically  observed,  it  would 
be  discovered  that  a  large  number  of  severe  cases  are  ushered  in  with 
and  maintain  a  temperature  ranging  from  102°  to  106°.  So  deceptive 
are  the  cool  skin  (especially  of  the  extremities)  and  the  clammy  sweat 
produced  by  relaxation  consequent  upon  the  nausea,  vomiting,  and 
diarrhoea,  that  the  high  internal  temperature  is  liable  to  escape  obser- 
vation unless  the  thermometer  is  introduced  into  the  rectum. 

Baths. — In  acute  cholera  infantum  baths  are  of  paramount  import- 
ance, affording  more  positive  relief  and  contributing  more  to  the  cure 
than  all  other  measures. 

This  form  of  summer  diarrhoea  has  by  some  not  inaptly  been  regarded 
as  a  type  of  heat  stroke.  Whenever  the  temperature  exceeds  102°  F., 
a  cooling  procedure  is  indicated.  It  is  important  that  the  proper 
method  of  bathing  should  be  adopted,  and  that  its  rationale  be  well 
understood. 

In  these  cases  there  is  usually  profound  involvement  of  the  ner- 
vous system,  frequently  manifested  by  a  dull,  apathetic  countenance, 
sunken  eyes,  deadly  pallor,  cool  extremities,  not  rarely  terminating  in 
outspoken  eclamptic  seizures.  Medicines  and  stimulants  are  useless, 
because  the  stomach  and  rectum  do  not  tolerate  them.  The  child 
should  be  put  at  full  length  into  a  tub  of  water  at  90°,  after  its  face 
and  head  have  been  bathed  with  cold  water ;  gentle  friction  should  be 
constantly  made,  while  some  one  is  removing  with  a  pitcher  the  tepid 
water  and  replacing  it  by  ice  water  poured  over  the  side  of  the  tub 
farthest  from  the  patient's  body.  The  temperature  of  the  bath  is  thus 
gradually  lowered  to  80°.  If  there  be  marked  cerebral  disturbance, 
water  at  60°  may  be  poured  upon  the  head  and  shoulders  for  five 
seconds.  The  child's  body,  except  the  head,  must  be  entirely  sub- 
merged. Its  cries  and  protestations  of  chilliness  must  be  met  with 
gentleness,  yet  with  firmness.  For  five  to  ten  minutes  the  agitation 
of  the  water  and  friction  of  the  body  should  be  kept  up,  unless  cyano- 
sis of  the  face  or  decided  shivering  ensue;  The  latter  will  be  pre- 
vented by  active  friction,  which  stimulates  the  peripheral  circulation. 
It  is  advisable  to  tilt  the  tub  by  placing  a  book  or  brick  under  the 
lower  end,  so  that  the  feet  are  not  submerged,  and  may  be  thoroughly 
rubbed  during  the  bath. 

After  the  bath  the  child  is  placed  upon  a  linen  sheet,  previously 
laid  smoothly  upon  a  blanket.  If  the  rectal  temperature  before  the 
bath — and  it  should  always  be  taken  at  this  time — has  been  103.5° 


ENTEEO-COLITIS.  369 

or  higher,  the  child  is  wrapped  in  the  sheet  so  that  every  part  of  the 
body  and  extremities  is  well  covered  by  it,  the  blanket  is  snugly 
wrapped  over  and  tucked  under  the  body,  which  is  thus  left  to  dry. 
If,  on  the  contrary,  the  temperature  has  been  below  103.5°,  the  child 
should  be  gently  mopped  dry  and  its  clothing  be  replaced  at  once. 
Such  a  bath  is  almost  invariably  followed  by  a  calm  and  refreshing 
slumber,  from  which  the  child  awakens  bright  and  comfortable. 

Let  it  be  understood  that  the  object  of  this  bath  is  not  alone  to 
reduce  temperature,  although  this  is  an  important  incidental  result. 
We  have  here  a  vasomotor  enfeeblement,  as  evidenced  by  the  pallor 
of  the  entire  body,  even  when  a  high  temperature  is  registered  in  the 
rectum.  By  immersing  the  entire  body  in  tepid  water  we  produce  a 
mild  cutaneous  excitation,  which  is  gradually  increased  by  the  removal 
of  warm  and  the  addition  of  cold  water,  and  is  enhanced  by  frictions 
of  the  body  and  constant  agitation  of  the  cooling  water  against  the  skin. 
These  gentle  shocks  are  not  beyond  the  child's  reactive  capacity;  they 
are  succeeded  by  equally  gentle  reactions,  so  that  the  cutaneous  vessels 
dilate,  as  evidenced  by  redness  of  the  skin.  If,  in  addition,  the  face 
and  head  are  bathed  with  water  at  60°  or  below,  the  "  shock  "  and  re- 
action are  increased,  the  respiration  deepens,  and  the  heart  beats  with 
more  vigor  and  less  rapidity,  the  eye  brightens,  the  color  returns  to  the 
lips,  the  child  becomes  more  animated.  Eepetition  of  the  bath  must 
be  guided  by  the  effect.  If  reaction  is  feeble,  the  duration  of  the 
bath  demands  shortening;  it  may  be  advantageously  substituted  by 
an  affusion  over  the  shoulders  with  water  at  a  lower  temperature  (80° 
or  75°)  followed  by  friction.  i 

The  effect  of  a  skilfully  administered  bath  in  the  condition  of  nerve 
prostration  incident,  in  many  children,  to  acute  summer  diarrhoea, 
must  be  observed  to  be  fully  appreciated.  In  my  experience  it  has 
been  an  inestimable  boon,  affording  hope  and  comfort  under  the  most 
trying  and  desperate  conditions.  My  mind  still  retains  vivid  recollec- 
tions of  the  days  when  I  was  a  student  and  of  the  early  years  of  my 
practice,  when  the  condition  of  profound  adynamia,  usually  associated 
with  hyperpyrexia,  was  called  spurious  hydrocephalus,  and  the  patients 
were  allowed  to  die  under  blisters  to  the  nucha  and  small  doses  of  calo- 
mel, etc.  These  cases  do  not  now  come  under  my  observation ;  they 
are  forestalled  by  the  bath  and  by  more  rational  treatment,  foremost  in 
which  is  judicious  g astro-intestinal  irrigation. 

When  there  is  objection  or  prejudice  to  tub  bathing,  or  when  there 
is  extreme  jactitation,  or  when  there  are  convulsions,  the  little  patient 
may  be  placed  in  the  wet  pack,  or  the  bath  may  may  be  followed  by 
the  latter  to  maintain  the  calming  effect.  The  wet  pack  is  prepared 
by  wringing  out  of  water  at  a  temperature  of  from  60°  to  70°  a  small 
24 


370        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

linen  sheet,  folded  into  a  third  of  its  usual  size,  or  a  large  linen  towel, 
and  smoothly  laid  (folded  to  suit  the  size  of  the  child)  upon  a  blanket. 
The  child  is  snugly  wrapped  in  the  damp  sheet,  which  may  be  made 
more  wet  if  the  temperature  be  high  (see  Wet  Pack,  page  132).  The 
blanket  is  now  snugly  tucked  around  the  child,  so  as  completely  to 
envelop  it,  like  a  mummy,  to  prevent  evaporation.  This  pack  may  be 
continued  for  half  an  hour  or  longer  if  patient  sleeps.  If  the  temper- 
ature is  high  it  may  be  renewed.  The  procedure  may  be  repeated 
every  four  hoars,  if  indicated.  The  previously  tossing  child  will  usu- 
ally drop  into  a  tranquil  slumber,  from  which  it  should  not  be  aroused. 
After  the  wet  pack  the  trunk  should  always  be  gently  rubbed  with  a 
linen  cloth  not  quite  wrung  out  of  water  at  70°  F.,  and  dried. 

The  effect  of  the  pack  or  of  the  bath  is  readily  maintained  by 
abdominal  compresses  or  by  the  trunk  pack  at  70°,  repeated  every 
hour. 

In  the  subacute  forms  of  summer  diarrhoea  the  general  depression  of 
the  system  arising  from  the  great  drain  upon  the  blood  and  nervous 
system  indicates  hydriatric  procedures.  The  pulse  is  usually  rapid ;  the 
temperature  ranges  from  99°  to  101°,  with  occasional  exacerbations ;  the 
skin  is  inelastic ;  the  face  is  shrunken  and  sallow ;  in  short,  the  symptoms 
are  those  of  chronic  adynamia,  due  to  imperfect  nutrition.  To  stimu- 
late the  appetite,  improve  the  general  nervous  condition — in  a  word,  to 
refresh  the  entire  organism — should  be  our  therapeutic  endeavor.  The 
most  approved  tonics  and  stimulants  often  fail.  In  these  cases  general 
ablutions,  morning  and  evening,  are  preferable  to  baths.  The  child  is 
placed  upon  a  soft  woollen  blanket;  the  abdomen,  chest,  and  back  are 
rapidly  bathed,  not  sponged,  as  follows :  From  the  hollow  of  the  naked 
hand  water  at  a  temperature  of  75°  F.  is  poured  upon  the  skin,  which 
is  then  gently  rubbed  and  patted  with  the  same  hand.  This  is  repeated 
until  the  entire  body  has  thus  been  treated  as  far  as  the  knees  and 
elbows.  The  body  is  now  rapidly  dried  by  placing  it  upon  a  linen 
sheet,  using  friction  with  a  rough  towel  if  the  temperature  is  below 
99.5°,  and  by  gentle  mopping  if  it  is  above  100°  F.  If  the  temper- 
ature reaches  102°,  a  general  bath  is  indicated,  beginning  with  water 
at  a  temperature  of  95°,  which  is  gradually  reduced  by  agitation  and 
friction  to  85°.  Gentle  drying  follows.  The  treatment  may  be  re- 
peated twice  daily. 

The  refreshing  effect  of  these  procedures  has  been  so  frequently 
observed  that  I  do  not  hesitate  to  commend  them.  Many  modifica- 
tions may  be  applied  to  meet  the  various  symptoms  in  summer  diar- 
rhoea of  infants,  which  a  thorough  mastery  of  the  principles  of  hydro- 
therapy  will  readily  suggest.  Suffice  it  to  say  that  no  case  should  be 
regarded  as  intractable  or  too  desperate  until  some  form  of  hydriatric 


ENTERO-COLIT1S.  371 

procedure  (the  adaptation  of  which  to  each  case  often  requires  more 
judgment  than  for  that  of  medicinal  agents)  has  been  tried. 

The  following  case  illustrates  graphically  the  results  of  this  treat- 
ment: 

P.  S ,  infant,  six  months  old,  vigorous  and  healthy,  living  in  one  of  our 

best  houses  on  the  banks  of  the  Hudson,  had  been  -weaned  one  month.  Since  that 
time  he  had  been  suffering  from  occasional  diarrhoea,  which  had  been  treated 
with  more  or  less  success  by  my  friend,  the  late  Dr.  Frothingham,  and  myself  for 
a  week.  Vomiting  and  choleraic  stools  prompted  the  mother  to  summon  me  in 
haste.  I  found  the  little  fellow  a  changed  being ;  his  features  were  pinched, 
the  skin  was  cold  and  clammy  ;  the  eyes  were  sunken  ;  he  could  retain  nothing, 
the  bowels  ejected  a  thin,  green  fluid  about  every  half-hour,  sometimes  more 
frequently.  Dr.  J.  Lewis  Smith  was  summoned  in  consultation. 

In  the  mean  time  the  symptoms  grew  more  and  more  threatening  ;  the  pulse 
began  to  fail,  the  child  lay  with  upturned  eyes,  pinched  features,  rapid  shallow 
respiration  and  cold  extremities — on  the  brink  of  dissolution.  The  rectal  tem- 
perature, to  my  great  surprise,  was  106°  F.  A  cold  bath  was  immediately  ordered, 
although  the  proposition  so  shocked  the  mother  that  she  wrung  her  hands  in 
despair,  lest  the  infant  should  succumb  to  the  cold.  A  large  bathtub  was  half 
filled  with  water  at  90°.  The  infant,  whose  stony  gaze  indicated  the  approach 
of  eclampsia  or  impending  dissolution,  was  submerged  in  the  water,  except  the 
head ;  the  lower  and  upper  extremities  were  held  up  and  chafed.  Cold  water 
was  turned  on,  and  ice  water  was  added,  while  the  water  was  permitted  to  flow 
from  the  tub.  In  ten  minutes  the  temperature  of  the  water  was  reduced  to  80°. 
A  smile  now  passed  over  the  baby's  face,  his  eyes  lost  the  stare,  and  he  revived. 
His  rectal  temperature  began  to  fall,  and  in  ten  minutes  reached  100°.  He  was 
now  wrapped  in  a  cloth  wrung  out  of  water  at  80°,  from  neck  to  knees ;  hot- 
water  bags  were  applied  to  the  extremities,  and  he  was  carefully  covered.  He 
fell  into  a  sweet  slumber,  from  which  he  awoke  when  Dr.  Smith  arrived,  to  find 
him  rescued  from  immediate  danger.  A  wet-nurse  and  careful  attention  restored 
the  child  in  a  few  days. 

The  author  has  deemed  it  fit  to  enter  fully  into  the  prevention  and 
treatment  of  entero-colitis,  because  these  depend  chiefly  upon  hygiene 
and  water  treatment  for  success.  Hygiene  has  always  been  intimately 
associated  with  hydrotherapy ;  even  those  enthusiastic  advocates,  the 
•water-cure  doctors  and  hydropaths,  always  combine  hygienic  directions 
with  their  crude  hydrotherapy. 


CHAPTER   XVIII. 

ASIATIC  CHOLERA. 

DESPITE  the  great  advances  made  in  recent  years  in  the  etiology 
and  prevention  of  this  dread  disease,  by  the  inestimable  researches  of 
Koch  and  his  followers,  the  treatment  still  is  an  opprobrium  medicorum. 

A  judicial  review  of  the  most  reliable  literature  on  this  subject 
would  lead  to  the  same  conclusion  which  Sir  Thomas  Watson  reached 
thirty  odd  years  ago,  viz.,  that  "we  have  made  no  impression  upon  the 
disease  by  medication." 

The  most  reliable  statistics*  give  the  result  of  fifteen  epidemics 
occurring  between  1831  to  1873,  in  which  28, 753  persons  were  attacked, 
of  whom  65.8  per  cent  died.  In  the  Hamburg  epidemic  17,975  cases 
occurred,  with  a  mortality  of  42.3  per  cent.  Since  this  disease  has 
resisted  so  successfully  the  most  varied  medication,  it  may  be  of 
interest  to  inquire  what  has  been  done  and  what  may  be  done  by  non- 
medicinal  management,  especially  by  hydr other apy. 

In  the  prophylaxis  of  cholera  cleanliness  plays  an  important  role. 
This  is  an  accepted  fact.  Hence,  frequent  bathing  with  warm  water 
and  soap  must  certainly  be  sanctioned.  But  this  is  not  all  that  is 
needed.  We  have  the  authority  of  Sir  Thomas  Watson  for  the  state- 
ment that  people  accustomed  to  daily  cold  bathing  were  often  exempt 
from  cholera.  It  is  reported  that  during  the  epidemic  of  1850  not  one 
member  of  the  "  Association  of  Water  Friends"  in  Berlin  was  attacked 
by  cholera.  Upon  general  principles,  as  well  as  upon  actual  ex- 
perience, the  daily  cool  or  cold  plunge,  or  rapid  ablution  with  friction, 
may  be  regarded  as  a  valuable  prophylactic  agent  during  an  epidemic,  f 

In  the  treatment  of  cholera  subcutaneous  and  intravenous  injections 
of  a  normal  salt  solution  have  in  recent  times  been  regarded  as  valu- 
able. But  the  former  did  not  afford  brilliant  results  in  the  Hamburg 
epidemic ;  the  latter  proved  only  a  good  stimulant  in  the  algid  stage, 
and  did  not  tend  to  save  lives. 

*  Albu,  in  "  Realencyclopadie, "  Bd.  iv. ,  p.  248. 

f  Hippocrates  mentions  the  success  of  cold  affusions  upon  the  abdomen  in 
severe  diarrhoea.  He  relates  the  history  of  the  wife  of  Antimachus  of 
Larissa,  in  whom  the  diarrhoea  was  cured  by  this  procedure,  although  the 
patient  died.  Rufus  of  Ephesus  recommended  about  the  middle  of  the  first 
century  cold  sitz  baths  for  the  treatment  of  profuse  diarrhoeas. — Eulenberg'f? 
"  Realencyclop. , "  241-15,  p.  152. 


ASIATIC   CHOLERA.  373 

Hydrotherapy. — That  water  has  proved  itself  superior  to  the  opiate 
or  other  treatment  of  cholera,  though  attested  by  the  most  indisputable 
evidence,  is  still  almost  unknown  and  certainly  unappreciated  by  the 
medical  profession. 

In  1831  Professor  Guenther,  director  of  the  Allgemeines  Kranken- 
haus  at  Vienna,  ordered  the  entire  surface  of  the  body  washed  with 
sponges  or  cloths  dipped  in  cold  water,  and  active  friction  with  pieces 
of  ice  made  over  the  extremities  and  sometimes  over  the  entire  body, 
until  it  became  warm,  which  was  usually  the  case  in  five  or  six  min- 
utes. The  patient  was  now  wrapped  up  in  hot  blankets. 

Professor  Casper,  of  Berlin,  placed  the  patient  in  an  empty  tub,  if 
he  was  dry ;  or  in  one  containing  lukewarm  water  (92°  F. )  as  far  as 
the  navel,  if  perspiring,  and  poured  three  to  five  buckets  of  ice-cold 
water  over  the  head,  chest,  and  back  every  two  or  three  hours.  After 
this  the  patient  was  dried,  rubbed,  and  put  into  warm  blankets.  Cas- 
per correctly  terms  this  a  warming  method. 

Professor  Sachs,  of  Konigsberg,  says  that  cold  water  is  a  remedy 
whose  omission  in  cholera,  when  it  can  be  used,  he  would  regard  as  an 
unpardonable  violation  of  duty. 

Dr.  Wagner,  who  was  active  in  the  epidemics  of  1831,  1832  to 
1836,  regards  the  cold  affusion  as  of  the  best  service.  "  Its  effect, 
when  it  is  indicated  and  successfully  applied,  is  brilliant  and  almost 
incredible. " 

The  French  minister  of  commerce  sent  Drs.  Grimaud  and  Martin 
to  Germany  to  study  cholera,  which  was  then  advancing  toward  France. 
These  gentlemen  reported  that  "  of  all  the  methods  employed,  that  by 
cold  has  proved  the  most  efficacious,  because  the  number  cured  is 
double  the  number  of  those  who  died,  a  proportion  not  obtained  in 
any  other  country." 

It  should  be  borne  in  mind  that  these  citations  are  not  from  hydro- 
paths,  or  water-cure  doctors  and  enthusiasts,  but  mostly  from  hospital 
physicians  and  professors  of  medicine  at  their  respective  universities. 
They  are  confirmed  by  the  reports  of  Winternitz  and  Vogl,  and  this 
method  is  susceptible  of  a  more  logical  rationale  than  is  any  other 
treatment  thus  far  proposed  in  cholera. 

To  Wilhelm  Winternitz  we  are  indebted  for  a  correct  rationale  of 
the  action  of  water  in  cholera,  which  is  the  same  as  in  other  infectious 
diseases,  viz.,  to  counteract  the  toxic  agencies  under  which  the  system 
is  tottering,  to  improve  the  circulation,  restore  warmth,  and  increase 
urinary  elimination.  He  has  the  patient  rubbed  with  a  sheet  wrung 
out  of  water  at  50°-60°  F. ;  this  is  followed  by  sitz  baths  of  60°-70°  F. 
for  ten  to  twenty  minutes,  the  patient  is  dried  and  placed  into  a  warm 
bed.  This  is  repeated  every  hour  or  two. 


374        THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

We  have  ample  warrant  for  this  rational  treatment  in  its  successful 
application  in  the  algid,  pernicious  forms  of  malarial  fevers,  in  which 
Dr.  Osier  advises  placing  the  patient  in  a  tub  and  douching  with  cold 
water,  and  of  which  that  veteran  in  therapeutics,  George  B.  Wood,  has 
said :  "  If  there  be  any  power  of  reaction  left  it  is  apt  to  be  awakened 
by  the  shock."  Similar  conditions  exist  in  cholera. 

Dr.  A.  Vogl,  chief  of  the  medical  army  staff  at  Munich,  says:* 
"  Because  of  the  lowered  surface  temperature  in  cholera,  all  the  vari- 
ous methods  of  treatment  hitherto  in  vogue  were  combined  with  the 
application  of  warmth.  We  may  raise  the  temperature  of  a  cholera 
patient's  skin  by  wrapping  him  in  hot  cloths,  wet  or  dry,  just  as  we 
may  do  for  a  corpse.  But  the  necessary  reaction,  which  maintains  the 
heat  at  the  periphery  and  sets  aside  its  concentration  in  the  interior  of 
the  body,  is  lacking,  or  occurs  only  in  slight  degree.  Indeed,  hot 
applications  act  inversely  by  maintaining  a  passive  heat. 

"  The  majority  of  the  reporters  from  the  latest  epidemic  (1892)  have 
declared  themselves  opposed  to  such  warming,  and  especially  to  the 
hot  bath ;  they  are  divided  in  favor  of  milder  procedures  in  the  form 
of  tepid  baths,  packs,  etc.  Still,  the  middle  course  is  not  always 
advisable,  especially  when  we  may  expect  results  from  decided  treatment. 

"  Even  in  the  earliest  times  physicians  thought  ice  rubbing  the  most 
effective  means  of  correcting  the  icy  coldness  of  the  skin  and  weakness 
of  the  heart  in  the  algid  stage.  Among  members  of  our  society  such 
men  as  Pfeifer,  Dietl,  Leitz,  Ernst,  Buchner,  Schleiss,  Graf,  have 
used  this  agent  and  declared  themselves  decidedly  in  favor  of  it.  Rub- 
bing the  calf  muscles,  when  they  are  as  tense  as  a  board  in  cholera,  with 
ice  relieves  more  quickly  than  an  injection  of  morphine. 

"  In  the  epidemic  of  1873-74,  patients  in  the  algid  stage  were  ener- 
getically rubbed  all  over  the  body  with  large  smooth  pieces  of  ice  until 
the  skin  became  intensely  red;  they  were  then  wrapped  in  warm  cov- 
erings, and  the  procedure  was  repeated  as  indicated.  After  this  treat- 
ment, reaction,  with  dilatation  of  the  capillary  area  and  perspiration, 
was  a  sure  indication  of  progress  toward  recovery. 

"  I  consider  it  of  the  greatest  importance  to  bring  subcutaneous  infusion 
to  its  desired  efficacy.  Infusion  will  accomplish  results  when  nothing 
more  can  be  expected  of  hydrotherapy,  when  the  circulation  has  been 
promoted  by  cold  applications.  The  powerful  diuretic  effect  of  cold 
procedures,  which  is  sure  to  ensue,  must  also  be  considered. 

"  The  majority  of  medical  men  still  fail  to  appreciate  the  intimate 
connection  existing  between  the  peripheral  and  central  circulation.  It 
has  often  been  demonstrated  that  an  attack  of  obstinate  catarrhal 

*MUeberdie  Korperwarme  und  Therapie  in  den  verschiedenen  Stadien 
der  Cholera."  Munchener  med.  Woch..  1893. 


ASIATIC   CHOLERA.  375 

colitis  which  has  resisted  all  methods  of  internal  treatment  is  easily 
controlled  by  the  simplest  external  application  of  cold  water,  such  as 
cold  packs,  and  the  diarrhoea  of  typhoid  fever  has  often  been  checked 
by  cold  baths.  Dietl's  claim,  that  '  while  cholera  is  one  of  the  most 
dangerous  diseases,  it  is  also  one  of  the  most  curable,'  should  not  be 
ridiculed. 

"  Method  Practised  in  the  Munich  Military  Hospital. — Early  Stage. — 
The  rectal  and  axillary  temperatures  were  taken ;  the  patient  was  then 
enveloped  standing  in  a  cold  wet  sheet,  and  rubbed  down  until  the  sur- 
face of  the  body  became  warm.  After  three  to  five  minutes'  rubbing 
he  was  wrapped  up  in  a  blanket  and  put  into  a  sitz  bath  at  a  tempera- 
ure  of  50°  F.,  where  he  remained  fifteen  minutes,  being  rubbed  continu- 
ously by  the  attendants.  He  was  now  put  to  bed  with  a  compress 
wrung  out  of  water  at  a  temperature  of  50°  F.  applied  over  the  abdo- 
men. By  this  time  the  patient  began  to  perspire  and  feel  comfortable. 
If  diarrhoea  appeard  within  four  to  six  hours  the  same  treatment  was 
repeated,  which  was  rarely  needed.  No  internal  medication  was 
given.  Of  sixty-four  cases  of  choleraic  diarrhoea  received  into  the 
hospital,  not  one  received  a  grain  of  opium.  Most  of  them  were  treated 
with  the  cold  compress  and  cured  in  eight  to  ten  days ;  only  a  few 
cases  progressed  to  cholerine  or  cholera.  Developed  mild  cases  of 
cholera  were  treated  in  a  similar  manner  and  absorption  of  the  subcu- 
taneous injection  was  thus  facilitated. 

"  Algid  State. — When  dejections  were  abundant  we  limited  ourselves 
to  rubbing  with  the  cold  wet  sheet  and  cold  abdominal  wet  compresses, 
with  an  early  resort  to  subcutaneous  saline  infusions. 

"  Inject  a  syringeful  every  minute  till  the  pulse  returns ;  then,  once 
in  five  minutes,  and  later  once  every  half-hour.  And  not  till  the 
urine  is  secreted  in  considerable  quantity  should  this  procedure  be 
stopped. 

"  Clinical  as  well  as  post-mortem  observations  have  taught  us  that 
the  shock  in  the  pre-algid  stage  is  due  to  the  rapidity  of  transudation 
rather  than  to  its  quantity.  Whatever  may  be  its  cause,  the  object  of 
our  treatment  must  be  to  strengthen  the  action  of  the  heart  and  accel- 
erate the  circulation  of  the  blood  which  has  become  stagnant.  For 
this  purpose  no  procedure  is  more  effective  than  such  a  thermic  and 
mechanical  irritation  of  the  skin,  as  is  produced  by  the  above-outlined 
treatment ;  and  the  greater  the  collapse  the  more  urgent  the  indications 
for  its  employment." 

The  large  material  at  Dr.  Yogi's  disposal  and  his  responsible 
official  position  conspire  to  render  his  views  of  exceptional  value. 
Since  he  dispenses  with  medicinal  treatment,  which  has  in  other  hands 
also  proven  so  fatal,  we  invite  the  attention  of  the  reader  to  a  careful 


376       THE  PRINCIPLES  AND   PRACTICE  OF  HYDROTHERAPY. 

perusal  of  this  logical  paper  by  a  hospital  physician  who  is  not  a  water 
doctor,  but  who  utilizes  every  remedial  agent  for  the  benefit  of  his 
patients. 

The  addition  of  enteroclysis  enhances  the  effect  of  external  hydro- 
therapy. 

Enteroclysis  has  been  referred  to  as  a  valuable  agent  in  the  treat- 
ment of  Asiatic  cholera.  It  was  brought  prominently  before  the  med- 
ical profession  by  Dr.  Elmer  Lee,*  who  applied  it  in  the  cholera 
region  of  Russia,  Germany,  and  France,  during  the  summer  of  1892. 
Upon  the  theory  that  cholera  is  a  disease  resulting  from  the  introduc- 
tion of  filth  into  the  stomach  and  intestinal  canal,  he  thought  it  desir- 
able to  bend  every  energy  to  the  removal  of  this  "filth."  This  should 
be  done  if  possible  before  the  system  was  overwhelmed  by  the  toxin 
arising  from  its  presence  in  the  intestinal  canal.  The  effect  of  passing 
into,  through,  and  out  of  the  large  bowel  of  two  or  three  gallons  of 
warm  water  with  soap,  is  not  only  directly  to  remove  the  accumulated 
contents  of  the  large  bowel,  but  secondarily,  through  the  sympathetic 
nervous  action  of  the  muscular  organism  of  the  small  intestine,  almost 
completely  to  carry  off  its  liquid  contents,  including  every  form  of 
bacterial  life.  When  the  intestinal  canal  is  cleared  of  this  hurtful 
and  filthy  mass,  great  relief  is  experienced.  The  full  benefit,  how- 
ever, can  be  obtained  only  by  early  treatment. 

"  The  plan,  as  finally  adopted  in  St.  Petersburg,  was  to  take  the 
patient  from  the  ambulance  to  the  bathroom,  without  delay,  and  when 
the  clothes  were  removed,  the  patient  was  laid  on  his  back  on  the 
irrigating-table,  with  the  knees  drawn  up  and  the  muscles  of  the  abdo- 
men relaxed;  the  long  tube,  after  being  lubricated  with  soap,  was 
gently  pushed  into  the  rectum  and  urged  by  twisting  and  gentle  pres- 
sure into  the  lower  bowel,  as  high  as  it  could  be  made  to  go,  and  the 
stream  of  the  previously  prepared  solution  of  warm  water  and  soap, 
making  a  soapsuds,  was  allowed  to  run  into  the  colon.  When  the  colon 
became  filled,  the  pressure  exerted  would  force  the  water  to  seek  an 
outlet  back  through  the  bowel  and  out  of  the  opening  around  the  outer 
surface  of  the  tube  into  a  properly  constructed  receiving-vessel. 

"  After  the  bowels  have  been  cleansed,  the  patient  was  placed  in  a 
bath  of  warm  water  and  afterward  conducted  to  his  bed.  The  irriga- 
tion was  repeated  one  or  more  times.  The  average  number  of  times 
that  irrigations  were  given  in  St.  Petersburg  was  twice ;  occasionally  a 
third  irrigation  was  given,  but  frequently  one  irrigation  was  found 
sufficient.  Within  one  or  two  hours  after  flushing  of  the  bowel  the 
patient  would  have  from  one  to  three  or  four  evacuations,  which  would 
be  followed  by  an  interval  of  rest  and  cessation  of  from  twelve  to 
*  Medical  Record,  December  17th,  1893. 


ASIATIC   CHOLERA. 


377 


twenty-four  or  thirty-six  hours.  Eelief  of  the  spasm  of  the  intestinal 
muscles,  which  produced  the  intense  suffering,  followed  promptly 
upon  the  removal  of  the  irritating  contents,  and  the  administration  of 
morphine  was  not  required.  In  nearly  every  case  the  stomach  was 
also  irrigated  with  a  solution  of  salt  and  water.  After  this  combined 
treatment  vomiting  and  purging  in  most  cases  would  subside.  As  an 
internal  treatment  I  recommended  and  used  hydrogen  dioxide  diluted 
with  distilled  water,  given  in  cupful  doses  at 
intervals  of  three  hours,  with  the  object  of  fur- 
ther cleansing  and  disinfecting  the  intestinal 
canal. 

"  The  first  symptom  of  cholera  is  diarrhoea, 
a  signal  of  warning  which  may  be  recognized 
even  by  the  most  ignorant  peasant.  If  all  cases, 
without  waiting  for  a  bacteriological  diagnosis, 
were  brought  under  this  system  of  management 


Fio.  66.— Dr.  Elmer  Lee's  Irrigating  Apparatus  for  Cholera  Stations. 

it  would  be  reasonable  to  expect  recovery,  if  not  an  entire  escape  from 
the  disease.  The  lesson  to  be  impressed  upon  those  who  have  au- 
thority, and  upon  the  poor  and  working  classes,  is  that  in  times  of 
cholera,  upon  the  first  attack  of  diarrhoea,  they  should  use  irrigation. 
And  I  would  recommend  to  the  authorities  the  establishment  in  the 
districts  of  towns  and  cities  of  a  simple  but  effective  apparatus,  to 
cleanse  the  bowels  effectually  by  a  process  of  irrigation  with  soap  and 
water. 

"The  irrigating- apparatus  consists  of  a  low  table  suitably  made,  as 
represented  in  the  accompanying  illustration  (Fig.  66).  Such  an  ap- 
paratus should  be  provided  near  the  homes  of  the  poorer  classes  as  well 
as  in  every  part  of  the  city,  and  a  physician  should  be  detailed  to  re- 
ceive and  treat  every  person  with  symptoms  of  looseness  of  the  bowels 
or  abdominal  colic.  Then,  if  thought  desirable,  the  patient  should  be 
transferred  to  a  hospital,  or  permitted  to  return  home. 


378        THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

"  That  the  interval  between  the  first  symptoms  of  cholera  and  the 
time  of  treatment  is  ofttimes  fatal,  is  a  lesson  which  would  go  far 
toward  relieving  anxiety  and  terror  in  cholera  times." 

The  number  of  cases  treated  by  Dr.  Lee  personally  was  twenty- 
seven  ;  the  total  number  of  deaths  was  three,  and  of  recoveries  twenty- 
three,  with  one  whose  recovery  was  not  complete  at  the  time  of  his 
departure. 

The  number  of  cases  treated  by  this  system  in  the  hands  of  the 
physician  of  the  hospital  amounted  to  nearly  one  hundred  at  the  time 
of  his  departure,  but  the  final  records  of  these  cases  are  yet  to  be  pub- 
lished. The  hospital  staff  at  St.  Petersburg  agreed  to  give  the  treat- 
ment a  trial  of  six  months. 

Dr.  Lee's  experiments  in  the  hospital  at  Hamburg  were  confined  to 
two  genuine  cases  of  cholera,  and  its  value  in  these  cases  was  manifest 
to  the  cholera  staff  of  physicians. 

Conclusions. — In  the  absence  of  personal  experience  in  the  treat- 
ment of  Asiatic  cholera,  I  have  endeavored  to  place  before  the  reader 
all  that  is  of  value  on  the  subject  of  hydrotherapy,  in  order  that  in 
future  epidemics  physicians  will  not  be  so  helpless  at  the  bedside  of 
the  cholera  patient.  The  disease  is  fatal  under  the  ordinary  treat- 
ment. The  text-books  on  practice  are  usually  silent  on  the  applica- 
tion of  water  in  this  disease.  Favorable  experience,  based  upon  ju- 
dicious rationale,  demands  that  external  and  internal  hydrotherapy 
be  given  a  fair  trial,  especially  as  the  seeming  boldness  of  these  pro- 
cedures finds  ample  warrant  in  the  rationale  and  in  their  success  in 
analogous  conditions. 

The  treatment  may  be  epitomized  as  follows :  1.  The  patient  should 
be  wrapped  early  in  a  linen  sheet  wrung  out  of  cold  water,  over  which 
he  is  rubbed  vigorously  and  slapped.  This  is  followed  by  hip  baths  (75°) 
for  five  to  fifteen  minutes,  with  constant  active  friction  by  two  attend- 
ants, to  prevent  chilling.  When  diarrhoea  is  abundant  or  the  teeth 
chatter,  the  patient  should  be  removed  earlier.  Several  sitz  baths 
should  be  provided,  so  that  the  patient  may  be  removed  from  a  soiled 
to  a  clean  bath  when  required.  After  thorough  drying  and  providing 
reaction,  the  patient  should  be  wrapped  in  a  warmed  blanket  and 
an  abdominal  compress  (50°)  applied.  2.  As  soon  as  another  move- 
ment occurs,  the  patient  should  receive  a  thorough  intestinal  irrigation 
and  a  large  subcutaneous  saline  infusion. 

These  procedures  should  be  alternated,  if  not  successful;  rapid 
rubbing  with  ice  may  be  substituted  for  the  wet  sheet.  The  temper- 
ature and  duration  of  the  sitz  bath  should  be  modified  to  suit  the 
case  and  the  character  of  the  epidemic,  in  accordance  with  the  ration- 
ale furnished  above.  Reaction  is  the  aim  of  therapy  in  this  dread 
disease. 


CHAPTER   XIX. 
INSOLATION. 

IN  the  management  of  cases  of  sunstroke,  which  have,  not  inaptly, 
received  the  appellation  of  "thermic  fever,"  the  application  of  water 
has  for  a  long  time  played  an  important  role. 

The  most  recent  text-books  teach  erroneously  that  hyperpyrexia  is 
the  chief  danger  in  this  disease,  and  that  every  effort  should  be  bent  to 
reduce  the  excessive  temperature,  by  bathing  the  patient  in  ice  water  and 
by  similar  faulty  methods.  I  desire  to  protest  earnestly  against  this 
view  of  the  therapeutic  indications  in  thermic  fever,  and  to  direct 
attention  to  the  fatal  fallacy  of  regarding  the  coldest  bath  as  the 
most  useful  heat-reducing  treatment. 

It  is  my  purpose  to  show,  as  clearly  as  the  principles  and  practice 
of  hydrotherapy  are  capable  of  demonstrating,  that  the  ice  bath  and  ice 
pack  so  universally  recommended  in  this  disease  are  absolutely  contraindi' 
cated,  dangerous,  and  based  upon  fallacious  reasoning.  In  avowing  so 
decided  a  departure  from  the  almost  universally  adopted  view,  the 
author  is  conscious  of  the  antagonism  he  invites.  But  he  purposes  to 
establish  the  correctness  of  his  opinion  by  theoretical  and  clinical  data, 
which  he  hopes  to  make  convincing,  and  thus  contribute  to  the  saving 
of  many  lives  which  are  now  sacrificed  by  reason  of  an  erroneous  con- 
ception of  the  disease  and  of  the  antithermic  effect  of  ice-water  baths. 

The  first  proposition,  viz.,  that  the  hyperpyrexia  theory  of  the 
treatment  of  thermic  fever  is  almost  universally  accepted,  is  demon- 
strated by  the  following  citations  from  standard  text-books : 

Taylor's  "Handbook  of  Practice"  (London)  says  (page  771): 
"The  temperature  must  be  reduced  as  quickly  as  possible;  if  ice  can 
be  procured  it  should  be  put  in  the  water  used,  or  it  may  be  rubbed 
directly  over  the  body  of  the  sufferer,  until  the  temperature  in  the 
rectum  nearly,  but  not  quite,  reaches  the  normal" 

Strumpell,  "Text-Book  of  Medicine,"  translator's  note,  says  (page 
748) :  "  Here  the  immediate  danger  is  from  hyperpyrexia,  which  must 
be  combated  by  rubbing  the  patient  with  ice,  placing  him  in  a  tub  of 
water  with  lumps  of  ice,  or  similar  measures,  until  the  temperature  in 
the  rectum  is  reduced  nearly  but  not  quite  to  the  normal  point.  In  the 
application  of  refrigerating  measures  the  head  must  not  be  neglected. 
The  sole  indication  at  first  is  the  reduction  of  the  temperature." 


380        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

Osier  says,  page  1,019 :  "  In  thermic  fever  the  indications  are  to 
reduce  the  temperature  as  rapidly  as  possible.  This  may  be  done  by 
placing  the  patient  in  a  bath  of  70°.  Rubbing  the  body  with  ice, 
practised  by  Darrach  in  the  New  York  Hospital  in  1857,  is  an  excel- 
lent procedure  to  lower  the  temperature  rapidly.  At  the  Pennsylvania 
Hospital  in  1887  the  ice  pack  was  used  with  great  advantage.  Of 
thirty-one  cases  only  twelve  died,  a  result  probably  as  satisfactory  as 
can  be  obtained." 

That  these  antithermic  methods  are  erroneous  it  is  the  aim  of  these 
pages  to  demonstrate  by  clinical  data  which  prove  the  superiority  of 
less  heroic  treatment. 

To  this  misconception  the  history  of  fever  treatment  offers  a  par- 
allel, which  may  aid  the  reader  in  appreciating  the  author's  position. 
The  text-books  of  twenty-five  years  ago,  when  referring  to  the  treat- 
ment of  typhoid  or  other  infectious  fevers,  dwell  in  precisely  the  same 
manner  upon  the  paramount  influence  of  high  temperature,  upon  the 
danger  of  hyperpyrexia,  and  upon  the  necessity  of  meeting  this  lethal 
symptom  at  all  hazards.  Cold  water  had  been  used  in  infectious 
fevers  with  more  or  less  success  from  the  earliest  days  of  medicine. 
Liebermeister,  Jurgensen,  and  others  urged  the  application  of  very 
cold  baths  as  the  best  antipyretic  in  typhoid  fever.  To-day  these 
authorities,  like  all  other  well-informed  physicians,  regard  the  cold 
bath  as  a  nerve  stimulant  rather  than  as  an  antipyretic,  and  its  tech- 
nique (see  page  168)  has  been  modified  in  accordance  with  this  view. 
If  the  reader  would  approach  the  consideration  of  the  subject  without 
prejudice,  he  should  bear  in  mind  the  historical  facts  that  for  centuries 
the  heat-reducing  theory  of  fever  has  dominated  the  medical  mind  and 
controlled  the  selection  of  remedies  for  fever;  that  from  1860  to  1890, 
and  even  later,  the  medical  profession,  with  very  few  exceptions,  be- 
lieved in  and  practised  the  antipyretic  methods,  and  that  cold  baths 
were  applied  as  the  most  valuable  measure  for  this  purpose.  When 
the  real  medicinal  antipyretics  of  the  coal-tar  series  were  discovered, 
the  question  of  successful  treatment  of  fever  seemed  to  approach  solu- 
tion. If  high  temperature  were  the  chief  lethal  factor  in  infectious 
fevers,  it  was  argued  that  the  positive  antithermic  properties  of  the 
coal-tar  products  offered  a  key  to  the  solution. 

How  faithfully  these  antipyretics  have  been  plied  for  many  years, 
how  sadly  disappointing  they  have  proved,  belongs  to  history.  Slowly 
but  surely  have  the  seemingly  victorious  antipyretics  retreated  from  the 
field,  first  in  the  large  hospital  centres,  where  exact  observation  more 
quickly  relegated  them  to  their  true  position  as  symptomatic  remedies; 
graduall}r  their  true  estimate  is  being  discovered  in  the  smaller  towns 
and  even  in  the  rural  hamlets  of  our  country.  The  teachings  of 


INSOLATION.  381 

Peabody,  Osier,  John  C.  Wilson,  Hare,  Tyson,  Billings,  Musser,  James, 
Loomis,  and  others  have  penetrated,  through  instruction  of  the 
younger  generation  of  physicians.  To-day,  the  correct  rationale  of 
cold  applications  in  fevers  is  that  furnished  on  page  174,  which  may 
be  epitomized  in  the  statement  that  they  stimulate  the  vasomotoi 
apparatus. 

Moreover,  while  cold  baths  have  always  improved  the  mortality  sta- 
tistics of  typhoid  fever,  their  systematic  use,  as  in  the  Brand  method, 
which  is  distinctly  an  antifebrile  rather  than  an  antithermic  bath  treat- 
ment, chiefly  by  reason  of  the  addition  of  mechanical  irritation,  has 
furnished  the  most  marvellous  reduction  of  mortality  in  the  history  of 
medicine  (page  202). 

When  the  writer  made  the  first  plea  for  this  method  before  the 
New  York  State  Medical  Society  in  1889,  the  Medical  Record  (Febru- 
ary 16th,  1889)  referred  to  it  editorially  (page  202)  as  follows : 

"  It  will  be  difficult  to  persuade  the  profession,  which  has  been  so 
long  under  the  dominion  of  the  laissez  faire  policy,  to  adopt  the  heroic 
method  of  cold  bathing.  There  seems,  however,  in  the  points  made, 
sufficient  ground  to  enlist  our  careful  reconsideration  of  the  whole  sub- 
ject. The  most  important  of  these  seems  to  us  the  emphasis  placed  upon 
the  object  of  the  cold  bath  being  anti-febrile  rather  than  merely  anti- 
thermic, inasmuch  as  its  action  is  chiefly  directed  toward  the  neutrali- 
zation of  the  febrile  toxemia  due  to  the  typhoid  process.  The  second- 
ary position  assigned  to  elevated  temperature  as  a  lethal  factor  may 
be  amply  sustained  by  recent  clinical  observations.  Lowering  temper- 
atures is  not  a  curative  measure." 

The  difficulty  of  winning  the  medical  profession  over  to  this  view 
is  apparent  in  the  medical  journals.  But  the  truth  was  "  mighty  and 
did  prevail."  Seven  years  later,  during  a  discussion  of  bathing  in 
typhoid  fever,  one  of  the  speakers  said :  *  "  The  tubbing  brought  the 
circulation  to  the  surface  and  acted  upon  the  nervous  system.  A  few 
years  ago  leading  men  in  the  profession  had  opposed  the  Brand  method 
in  this  hall,  while  to-night  no  voice  was  raised  in  opposition." 

I  purpose  to  show  that  "  history  repeats  itself"  in  the  prevalent 
antipyretic  treatment  of  thermic  fever  (sunstroke).  While  cold  is  even 
more  universally  utilized  in  insolation  than  it  ever  was  in  typhoid  fever, 
we  still  fail  to  obtain  the  best  results  from  it,  because  the  consensus  of 
medical  opinion  favors  its  use  as  a  temperature-reducing  agent — viz.,  for 
the  hyperpyrexia — precisely  as  was  formerly  done  in  typhoid  fever. 

Whether  the  theory  of  Wood  and  others  be  accepted,  that  "  thermic 
fever  is  due  to  a  paralysis,  under  the  influence  of  extreme  heat,  of  the 
centres  in  the  medulla  spinalis  which  regulate  the  disposition  of  bodily 

*Med.  Rec.,  January  9th,  1897,  p.  66. 


382        THE  PRINCIPLES  AND  PRACTICE  OF  HYDROTHERAPY. 

heat,  and  owing  to  this  disturbance  more  heat  is  produced  and  less  is 
given  than  normally ; "  or  the  theory  of  Jacubowitch  and  others,  "  that 
there  is  usually  an  increase  of  heat  from  muscular  action  (in  most 
cases  it  occurs  during  active  muscular  movements,  as  in  labor  or  march- 
ing), and  there  is  a  diminished  heat  loss  due  to  humidity  and  high 
temperature  of  the  atmosphere,"  or,  as  the  author  believes,  in  a  dis- 
turbance of  the  vasomotor  centres  as  in  typhoid  fever — the  fact  re- 
mains that  the  heat-diffusing  function  of  the  skin  has  become  impaired. 
The  latter  we  absolutely  know  and  need  not  theorize  upon.  Another 
point  which  we  absolutely  know  is  that  in  the  large  majority  of  autop- 
sies we  find  everywhere  in  the  body  enormous  dilatation  of  the  veins 
and  pronounced  narrowing  of  the  arteries. 

The  rise  of  temperature  is,  in  the  author's  opinion,  chiefly,  if  not 
entirely,  due  to  the  failure  of  the  enormous  area  of  skin  to  carry  off 
the  rapidly  accumulating  heat.  A  heat  stasis  ensues,  just  as  it  does 
in  typhoid  fever.  This  is  evidenced  by  the  pallid  or  cyanosed  appear- 
ance of  the  skin  (excepting  that  covering  the  face) .  We  have  precisely 
the  same  cutaneous  condition  in  typhoid  fever — a  paretic  condition  of 
the  peripheral  vessels.  So  long  as  typhoid  patients  were  plunged 
into  tubs  of  very  cold  water  *  or  were  wrapped  in  sheets  and  sprinkled 
with  ice  water  (see  page  511),  until  the  temperature  was  reduced,  so 
long  did  typhoid  fever  continue  fatal.  When  the  ignis  fatuus  of  hy- 
perpyrexia  ceased  to  affright  the  practitioner,  and  he  learned  to  apply 
cold  water  as  a  nerve  stimulant,  the  disease  became  more  tractable 
(see  rationale  of  the  cold  bath).  In  insolation  high  temperature  is 
now  regarded  as  the  chief  point  of  therapeutic  attack,  and  this  is  com- 
bated by  very  cold  and  prolonged  baths.  I  have  endeavored  to  de- 
monstrate the  fallacy  of  the  latter  idea  in  typhoid-fever  treatment,  and 
to  show  that  by  adding  to  the  cold  bath  active  friction  (Brand  method) 
the  life-saving  efficiency  of  the  latter  is  enhanced.  The  antifebrile 
effect  is  also  increased  by  friction,  because  it  restores  the  lost  tonicity 
to  the  cutaneous  vessels  and  admits  of  a  large  area  of  blood-vessels 
being  exposed  to  the  cooling  effect  of  the  bath.  Having  already 
entered  very  fully  upon  the  subject  elsewhere,  it  is  necessary 
only  to  reiterate  here  that  the  reduction  of  internal  temperature  by 
cold  baths  is  not  due  to  direct  cooling,  which  really  contracts  the 
cutaneous  vessels  and  drives  the  blood  from  the  surface,  causing,  if 
excessive  or  prolonged,  their  paralysis,  but  depends  rather  upon  the 

*In  theArchiv  fur  klin.  Med.,  Bd.  3  and  4,  Dr.  Krtlgkola  reports  from 
Duschek's  Clinic  60  cases  of  typhoid  fever  treated  by  cold  baths,  with  a 
mortality  of  28.3.  The  patients  were  laid  into  a  bath  of  60-65°  F.  without 
friction,  for  ten  minutes,  from  6  A.M.  to  10  P.M.,  whenever  the  temperature 
required  to  be  reduced. 


INSOLATION.  383 

extent  to  which  the  peripheral  nerves  and  vessels  are  excited  by  the 
cold  and  friction  or  mechanical  impact.  This  stimulus  is  conveyed  to 
the  central  nervous  system,  and  by  reflex  effect  removes  or  ameliorates 
all  the  serious  manifestations,  including  the  hyperpyrexia. 

It  remains  now  to  apply  this  physiological  fact  and  the  favor- 
able clinical  results  due  to  its  recognition  to  the  treatment  of 
insolation.  Does  the  ice  bath  or  other  heroic  water  treatment  really 
furnish  the  best  results?  Shall  we  continue  to  follow  the  teachings 
of  the  text-books,  and  with  might  and  main  reduce  the  temperature  of 
these  thermic-fever  cases  to  nearly  a  normal  point?  Let  clinical 
observation  answer  this  question,  as  it  has  answered  it  in  typhoid 
fever ! 

The  most  reliable  and  extensive  observations  upon  insolation  that 
have  been  made  in  recent  times  are  contained  in  a  paper*  presented  to 
the  New  York  Academy  of  Medicine,  May  20th,  1897. 

During  the  summer  of  1896  a  severe  epidemic  of  sunstroke  pre- 
vailed in  New  York  City,  which  furnished  during  the  week  ending 
August  15th  six  hundred  and  forty-eight  deaths — over  one-third  of 
the  entire  mortality. 

The  writer  collected  records  from  nearly  all  the  hospitals  in  the 
city.  "  There  were  five  hundred  and  twenty  hyperpyrexia  cases  treated, 
with  a  mortality  of  one  hundred  and  thirty-two.  Among  the  patients 
treated  by  means  of  baths  ranging  in  temperature  from  50°  to  75°, 
the  mortality  was  33£  per  cent.  In  the  Brooklyn  Homoeopathic 
Hospital,  where  baths  of  90°-110°,  reduced  in  from  fifteen  to  twenty 
minutes  to  72°,  were  given,  forty-nine  cases  were  treated,  with  a 
mortality  of  41.17  per  cent.  In  the  same  hospital  another  series  of 
cases,  treated  by  needle  spray  from  a  hose  attached  to  a  cold-water 
faucet,  gave  a  mortality  of  11.5  per  cent. 

"  At  the  Flower  Hospital  the  patient  was  stripped  and  put  on  a  cot 
covered  with  a  rubber  sheet,  an  ice  cap  applied  to  the  head,  and  three 
sections  of  hose  with  nozzles,  giving  a  fine  needle  spray,  were  fastened 
to  the  cold-water  faucet  and  the  patient  vigorously  sprayed  until  the 
rectal  temperature  was  reduced  to  103°.  The  patient  was  then  wrapped 
in  two  blankets.  If  the  temperature  rose  to  104°  or  105°,  the  spray- 
ing was  repeated  until  it  fell  to  101°.  Among  twenty-six  patients 
thus  treated,  with  a  body  temperature  averaging  108°,  three  died — 11.5 
per  cent. 

"  At  the  St.  Vincent  Hospital  the  patient  was  wrapped  in  a  cotton 
sheet  and  placed  on  a  stretcher,  which  was  covered  with  a  rubber 
sheet.  Dipperfuls  of  cold  water  were  forcibly  dashed  on  him  from  a 

*"  Sunstroke  as  it  Occurred  in  New  York  City  during  1896,"  Medical 
News,  July  24th,  1897,  by  Alexander  Lambert,  M.D. 


384       THE   PRINCIPLES  AND   PRACTICE   OF   HYDEOTHERAPY. 

distance  of  several  feet.  In  the  very  severe  cases  every  two  or  three 
minutes  a  small  stream  of  very  cold  water  from  a  pitcher  was  allowed 
to  fall  from  a  height  of  six  or  eight  feet  upon  the  patient's  forehead. 
This  treatment  proved  to  be  powerfully  stimulative,  and  was  continued 
until  the  temperature  fell  to  104°  or  103°.  The  patient  was  then 
wrapped  in  blankets  and  surrounded  with  hot  bottles.  The  body 
temperature  fell  slowly  to  normal  and  no  reaction  occurred.  Often 
after  a  short  interval  the  warm  pack  brought  on  sweating  and  the 
patient  slept.  Of  one  hundred  and  ninety-seven  hyperpyrexial  cases 
twelve  were  fatal — six  per  cent." 

These  figures  teach  a  valuable  lesson,  which  establishes  the 
correctness  of  the  views  I  desire  to  impress.  Although  hyperpyrexia 
seems  to  be  the  dominant  indication  in  this  author's  mind,  he  displays 
in  several  parts  of  his  paper  a  correct  estimate  of  the  value  of  cold 
water  as  a  nerve  stimulant.  He  condemns  the  ice  pack,  because  "  it 
prevents  proper  friction  and  is  not  stimulating,  as  the  cold  bath,  and 
therefore  not  so  efficacious." 

In  order  to  emphasize  the  danger  of  very  low  temperatures,  espe- 
cially of  ice  baths*  (i.e.,  submerging  the  patient  in  cold  water  for 
five  or  more  minutes)  and  ice  packs,  and  to  impress  upon  the  reader 
the  paramount  import  of  mechanical  irritation  of  the  skin  by  pressure 
in  the  delivery  of  the  water  upon  it,  the  following  summary  of  the 
effect  of  the  various  treatments  referred  to  above  is  offered : 

1.  Graduated  bath  (110°  to  72°,  fifteen  to  twenty  minutes),  mortal- 
ity, 41.17  per  cent. 

2.  Ice  pack,  mortality,  38.7  per  cent. 

3.  Cold  baths  (50°  to  75°,  ten  minutes  or  more),  mortality,  33.33 
per  cent. 

4.  Needle  spray  (75°,  stopped  when  temperature  reached  103°), 
mortality,  11.5  per  cent. 

5.  Affusions  with  force  (ice  water,  as  stopped  when  104°  or  103° 
was  reached,  O'Dwyer's  practice),  mortality,  6  per  cent. 

The  fact  that  Osier  regards  a  mortality  of  38.7  per  cent  as  "  about 
as  satisfactory  as  can  be  obtained"  indicates  how  fatal  is  sunstroke 

*  "By  an  ice  bath  is  meant  a  tub  bath  in  which  ice  crushed  into  moder- 
ates-ized  pieces  is  constantly  kept  floating.  The  temperature  of  the  bath 
is  about  40°  F.  Incessant  and  vigorous  rubbing  of  every  portion  of  the  body 
is  an  absolute  necessity.  When  the  bath  was  given  for  ten  minutes,  irre- 
spective of  the  height  of  temperature,  the  results  were  not  good. 

"The  ice  pack  was  given  by  placing  a  patient  on  a  rubber  sheet  and  pack- 
ing large  pieces  of  ice  along  and  between  the  legs  and  along  the  sides  of  the 
body.  The  upper  surface  of  the  body  was  rubbed  with  the  hands  and  pieces 
of  ice.  This  procedure  often  required  more  than  an  hour.  The  temperature 
almost  always  fell. " 


INSOLATION.  385 

under  the  customary  antithermic  treatment.  The  above  figures  demon- 
strate that  a  change  from  the  antithermic  procedures  (ice  baths  and 
packs)  to  the  real  nerve  stimulating  procedures  (douches  and  affu- 
sions) would  reduce  the  mortality  in  a  marked  degree.  They  offer 
clinical  proof  of  the  correctness  of  the  view  expressed  in  the  opening 
lines  of  this  chapter,  that  theory  and  practice  combine  in  condemn- 
ing the  ice  baths  and  ice  packs  recommended  and  reiterated  in  our 
text-books. 

As  in  typhoid-fever  treatment,  I  do  not  contend  that  hyperpyrexia 
is  to  be  regarded  with  indifference.  I  plead  for  the  recognition  of  nerve 
depreciation  as  the  chief  lethal  factor.  The  latter  is  anterior  to  the  hyper- 
pyrexia and  is  most  effectively  treated  by  brief  applications  of  cold  water 
applied  with  considerable  force  to  successive  parts  of  the  body.  The 
nerve  centres  are  so  overwhelmed  by  the  atmospheric  temperature  acting 
upon  predisposed  individuals  that  they  render  the  patient  incapable  of  re- 
sponding to  the  simultaneous  impact  of  very  cold  water  over  the  entire  body. 
The  greatest  mortality  reported  (41.7  per  cent)  is  under  the  bath  of 
90°  to  110°  reduced  gradually  to  72°,  and  that  next  to  the  lowest  mor- 
tality (11. 5  per  cent),  in  the  same  hospital,  where  a  needle  spray  of  75° 
with  good  pressure  was  applied  without  previously  heating  the  skin 
(and  thus  intensifying  the  most  obvious  etiological  factor).  Hence 
douches  and  affusions  are  superior  to  ice  baths  and  packs. 

Correct  Treatment. — The  correct  treatment  would  be  a  judicious 
adaptation  of  the  temperature  of  the  water,  the  mechanical  impact, 
and  the  duration  to  the  indications  existing  in  each  case.  The  nerve 
depreciation  being  overcome  by  judicious  management,  hyperpyrexia 
will  yield  with  the  other  manifestations  of  impaired  nerve  control.  The 
following  outline  may  serve  as  a  guide  to  the  management  of  thermic 
fever.  It  is  based  upon  the  principles  enunciated  in  this  work  and 
it  is  borne  out  by  the  clinical  data  which  have  been  marshalled. 

If  the  pulse  is  feeble  or  rapid,  skin  pale,  and  the  patient  conscious, 
temperature  above  103°,  treatment  may  be  begun  by  ablutions.  The 
patient,  lying  upon  a  rubber  sheet  which  is  covered  with  a  blanket,  is 
rapidly  bathed  and  rubbed  for  ten  minutes  with  a  wash  cloth  or  large 
crumpled  piece  of  surgical  gauze  saturated  with  water  at  75°.  If  the 
skin  shows  reaction,  this  ablution  may  be  repeated  in  half  an  hour 
with  water  at  70°,  again  in  half  an  hour  with  water  at  65°,  and  so  on 
until  the  rectal  temperature  falls  two  or  three  degrees.  It  is  a  serious 
error  to  continue  bathing  until  the  rectal  temperature  approximates  the 
normal  point ;  the  record  shows  that  many  succumb  with  a  normal 
temperature,  and  that  others  rapidly  and  fatally  fall  to  a  subnormal 
temperature.  It  is  far  more  prudent  and  effective  to  repeat  the  treat- 
ment after  the  system  has  had  time  and  opportunity  to  react  some- 


386        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

what,  and  to  decrease  the  temperature  of  the  water  and  increase  the 
force  of  its  impingement  by  slowly  pouring  it  from  a  greater  height  or 
using  a  jet  or  needle  douche  over  successive  parts  of  the  body,  never 
continuing  the  application  upon  any  part  which  is  already  cooled,  and 
never  exposing  the  entire  body  to  cold  baths. 

The  sheet  bath  (page  115)  affords  an  excellent  procedure  in  cases 
with  very  high  temperature.  In  comatose  cases  water  at  50°  to  40°, 
delivered  by  a  douche  or  by  forcible  affusion  from  basins  at  short 
intervals  over  successive  parts  of  the  body,  will  afford  the  best  results. 
Here,  too,  care  should  be  exercised  not  to  depress  the  nerve  centres  by 
long-continued  application  of  very  cold  water.  Reaction  must  be 
induced. 

Repeated  sprinklings  or  vigorous  affusions  with  water  at  60°,  re- 
duced each  time  a  few  degrees,  and  accompanied  by  friction,  would  be 
good  practice  where  a  hose  with  good  pressure  cannot  be  obtained. 

If  hyperpyrexia  continues  despite  the  above-mentioned  methods,  a 
hammock  bath  (page  240)  of  95°  F.  for  one  hour  offers  the  most 
effective  and  least  harmful  antithermic  procedure.  This  may  be 
terminated  by  cold  affusions  if  stupor  persists. 

Above  all  things,  routine  must  be  eschewed.  Judgment  and  skilful 
adaptation  to  each  individual  case  will  afford  in  these  trying  cases  the 
same  good  results  which  judicious  hydrotherapy  has  achieved  in  other 
serious  acute  diseases.  The  lesson  of  history,  presented  by  cold  bathing 
in  typhoid  fever,  needs  to  be  earnestly  accepted.  I  fear,  however,  that 
much  time  may  elapse  ere  the  warning  here  emphasized,  "  beware  of 
the  ice  bath  and  ice  pack, "  will  succeed  in  neutralizing  the  teachings  of 
the  text-books,  which  in  many  instances  are  the  reiteration  of  previ- 
ous teachings  rather  than  the  outcome  of  bedside  observation. 

It  is  the  chief  aim  of  this  work  to  impress  upon  the  practitioner 
the  true  principles  of  hydrotherapy.  In  no  disease  are  they  so  well 
illustrated  to-day  as  in  the  true  and  false  treatment  of  insolation. 


CHAPTEE  XX. 


THE   HOT-AIR  BATH. 

DIRECTLY  connected  with  the  application  of  water  in  disease,  the 
hot-air  bath  has  long  been  in  use  for  enhancing  the  reactive  capacity  of 
patients  about  to  be  subjected  to  hyd^iatric  procedures.  An  arrange- 
ment for  home  use  may  be  improvised  by  seating  the  patient  upon  a 
chair  provided  with  a  wooden  seat,  the  bottom  of  which  is  covered 
with  tin  or  sheet  iron.  A  large  alcohol  or  gas  lamp  is  placed  under 
the  chair,  upon  a  tin  pan.  The  patient  is  covered  with  a  sheet  which 
is  secured  around  his  neck,  and  over  this  a  rubber  sheet  is  similarly 
secured.  When  the  lamp  is  lighted  the  air  surrounding  the  patient 
may  be  heated  to  the  required  temperature. 

An  apparatus  (Fig.  67) 
for  use  in  bed,  devised  by 
Fulpius,  appears  to  be  prac- 
tical. It  consists  of  a  wood- 
en box  seventy  centimetres 
long,  fifteen  centimetres 
wide  and  deep.  Into  this 
box  a  pipe  about  sixty  centi- 
metres long,  which  is  con- 
nected with  the  lamp,  enters 
and  conveys  the  heated  air 
to  a  space  formed  upon  the 

bed  by  two  wooden  poles,  which  reach  and  are  secured  to  the  pillow. 
The  patient  being  placed  upon  the  bed,  the  box  is  laid  across  the  foot  of 
the  latter  and  the  poles  are  secured.  Blankets  are  now  so  placed  that 
the  patient  is  entirely  surrounded  by  the  hot  air  streaming  upon  him. 

The  dry  pack  described  in  the  article  on  Phthisis  Treatment  is  a 
useful  procedure  for  surrounding  the  patient  with  hot  air  without  sub- 
jecting him  to  agitation. 

For  institutions  the  hot-air  cabinet  is  a  complete  apparatus. 
Rationally  and  not  indiscriminately  applied,  as  is  done  in  the  ordinary 
Turkish  baths,  but  in  the  form  of  what  the  French  call  etuve  seche,  the 
hot-air  bath  presents  many  advantages. 

The  apparatus  devised  by  the  author  which  is  in  use  in  the  Hydri- 


Fia.  67.— Hot-Air  Bath  for  Domestic  Use  (Glax). 


888       THE   PRINCIPLES  AND   PRACTICE   OF   HYDBOTHERAPY. 

atric  Department  of  the  Riverside  Baths,  in  the  Vanderbilt  Clinic 
(Columbia  University),  and  at  the  Park  Avenue  Hydriatric  Institute, 
consists  of  three  wooden  cabinets  (see  page  401).  Practical  expe- 
rience with  this  apparatus  for  many  years  proves  it  to  be  absolutely 
perfect,  though  very  simple.  The  temperature  of  the  air  surrounding 
the  patient  is  controlled  by  a  valve,  and  may  easily  be  raised  to  180° 
or  over.  This  is  rarely  necessary,  however.  The  pulse  and  mouth 
temperature  may  be  taken  and  recorded  every  ten  minutes.  After  the 
desired  rise  of  temperature  and  increase  of  perspiration  are  obtained, 
the  patient  is  subjected  to  whatever  procedure  is  indicated.  * 

Rationale. — An  individual  surrounded  by  hot  air,  i.e.,  from  120° 
F.  up  to  a  point  of  tolerance,  absorbs  an  enormous  quantity  of  heat 
through  the  heating  of  the  blood  in  the  cutaneous  vessels.  This  is 
made  quite  evident  in  the  rise  of  the  temperature  of  the  mouth,  which 
is  not  exposed  to  the  direct  influence  of  the  hot  air,  the  head  being 
exposed  in  the  cabinet  bath.  The  author's  investigations  apply  only 
to  the  latter.  The  effect  of  hot-air  baths  on  man  has  been  studied  by 
Tetatmik,f  who  found  that  the  number  of  leucocytes  was  diminished 
by  from  5.45  per  cent  to  7.43  per  cent.  There  are  abundant  diapho- 
resis, an  increase  in  the  body  temperature,  increase  of  pulse  and  respi- 
ration, diminution  of  muscular  power  and  vital  capacity  of  the  lungs, 
enfeeblement  of  inspiration  and  expiration,  decided  enhancement  of 
tissue  change  and  assimilation,  and  diminution  of  arterial  tension. 

The  viscosity  of  the  blood,  according  to  Lommel,|  is  decidedly  in- 
creased, as  also  the  number  of  erythrocytes. 

According  to  Linser  and  Schmid,§  there  is  a  decided  influence  of 
hyperthermia  upon  metabolism;  this  effect  begins  in  a  medium  of  104° 
and  is  enhanced  by  higher  media. 

We  have  here  three  factors — the  thermic  irritation,  the  heat  supply 
or  loss,  and  the  protective  action  of  the  organism  against  these.  The 
temperature  equilibrium  of  the  human  body  is  due  to  two  constantly 
active  factors — heat  production  and  heat  diffusion.  These  are  under 
control  of  the  nerve  centres,  which  are  connected  on  the  one  hand  by 
cerebro-spinal  and  sympathetic  fibres  with  the  nerves  of  the  skin;  and, 
on  the  other,  with  the  abundant  capillary  network  of  the  skin  and 
muscles,  both  of  which  respond  to  the  slightest  temperature  impres- 
sions by  narrowing  or  dilating  the  cutaneous  or  muscular  capillaries. 
Thus  are  the  production  and  diffusion  of  heat  regulated.  It  becomes 

*  The  electric-light  bath  differs  from  the  hot-air  bath  in  its  power  to  pro- 
duce all  the  effects  of  superheated  air  more  rapidly  and  with  less  elevation  of 
the  box  temperature.  Its  suggestive  effect,  however,  is  not  to  be  disregarded. 

f  These  de  St.  Petersburg,  1893. 

\  Fortschritte  der  Medizin. 

8  Loc.  cit. 


THE  HOT-AIR  BATH.  389 

evident  that  this  responsive  action  of  the  nervous  system  varies  in 
different  individuals,  and  even  in  the  same  individual  at  different  times. 

In  five  minutes  usually  the  pulse  rate  begins  to  increase;  five  min- 
utes more  mark  a  rise  of  temperature  and  an  increase  of  respiratory 
movements.  The  average  normal  patient  may  within  half  an  hour  be 
made  to  register  an  increase  of  thirty  to  fifty  pulse  beats  and  one  to 
three  degrees  of  temperature. 

The  skin  becomes  hypersemic  and  succulent,  and  its  tactile  and 
electrical  sensibility  is  heightened.  Owing  to  the  absence  of  a  muscu- 
lar coat,  the  capillaries  are  really  only  thin  structures,  practically 
elongations  of  the  inner  arterial  coats,  and  depend  for  firmness  and 
elasticity  upon  the  surrounding  structures.  As  the  latter  are  ex- 
panded by  heat  applied  to  them,  it  follows  that  the  thread-like  capil- 
lary must  become  dilated  to  many  times  its  calibre,  and  be  thus  made 
to  receive  more  blood. 

It  has  been  ascertained  by  the  plethysmograph,  which  measures  the 
volume  of  parts  exactly,  that  not  only  does  the  body,  especially  the 
extremities,  increase  in  circumference,  but  that  the  increased  activity 
of  the  heart  sends  more  blood  to  the  non-resisting  and  enlarged  capil- 
laries and  arterioles.  That  such  an  enormous  diversion  of  blood  to 
the  surface  must  change  the  existing  conditions  of  the  circulation,  dis- 
gorging the  venous  system,  the  kidneys,  liver,  and  spleen,  may  be 
easily  understood.  Blood  pressure  is  reduced,  there  is  a  loss  of  ten- 
sion of  the  vessel  walls.  The  heart  becomes  fatigued  and  must  labor 
to  send  the  blood  forward,  because  the  peripheral  resistance  is  dimin- 
ished. On  this  principle  may  be  explained  the  faintness,  tinnitus 
aurium,  and  the  symptoms  of  cerebral  anaemia  which  sometimes  ensue, 
and  which  are  more  frequent  in  the  Turkish  bath,  where  hot  air  is  in- 
haled and  thus  locally  applied  to  the  pulmonary  capillaries  also.  Usu- 
ally some  cold  procedure  follows  ;  the  surface  temperature  is  reduced 
by  the  cold  bath  or  douche;  the  previously  anaemic  internal  organs  be- 
come again  full  of  blood.  This  effect  explains  the  danger  if  there 
exists  a  brittle  condition  of  the  vessel  coats  or  a  cardiac  lesion. 

For  this  reason  it  is  best  in  elderly  or  otherwise  feeble  persons  to 
lower  the  water  temperature  after  the  hot-air  bath  gradually,  to  allow 
the  inner  organs  to  accommodate  themselves.  If  the  proper  douching 
and  friction  have  been  practised  after  a  hot-air  bath,  the  skin  will  re- 
main sufficiently  hyperaemic  to  present  a  rosy  hue.  This  positive  dif- 
ference in  effect  upon  the  peripheral  and  secondarily  upon  the  internal 
circulation,  between  the  hot-air  bath  and  the  cold  douche  following 
it,  renders  it  evident  that  the  former  produces  a  relaxation,  while  the 
latter  is  followed  by  a  tonic  condition  of  the  cutaneous  vessels  which 
assists  the  heart  in  propelling  the  blood  through  them.  The  pulse  re- 


390        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

mains  somewhat  more  frequent,  becomes  soft,  and  the  blood  pressure 
is  lowered  a  little.  The  therapeutic  advantages  arising  from  this  con- 
dition are  self-evident. 

The  respiration  is  as  much  affected  by  the  hot-air  bath  as  the  circula- 
tion. The  thermic  irritation  of  the  periphery  excites  reflexes  which 
accelerate  the  breathing;  besides  this,  the  superheated  blood  stimu- 
lates the  vagus  also.  I  have  often  noted  a  respiration  of  thirty  a 
minute,  although  the  inspirations  were  deep.  The  subsequent  cooling 
process  reduces  the  number  of  respirations  according  to  its  intensity 
and  rapidity,  although  they  remain  more  frequent  than  normal  for  a 
time. 

There  is  an  increased  excretion  of  C0a  and  increased  demand 
for  oxygen,  clear  manifestations  of  increased  oxidation.  The  urine 
affords  corroborative  evidence  on  this  point,  and  this  evidence  is  the 
more  valuable  since  we  may  obtain  it  with  some  degree  of  precision. 
The  quantity  of  urine  is  reduced  about  one-fourth  by  the  hot-air  bath 
in  persons  who  take  constantly  the  same  amount  of  fluid.  This  reduc- 
tion is  not  so  great  at  the  time  of  the  bath  as  during  the  four  or  five 
days  succeeding  it. 

This  may  fairly  be  explained  by  the  effort  which  the  organism  is 
called  upon  to  make,  in  order  to  eliminate  the  waste  products  which 
the  bath  produces.  The  specific  gravity  of  the  urine  increases  in  pro- 
portion to  the  diminution  of  the  quantity,  but  this  increase  continues 
even  after  the  urinary  volume  is  restored  to  normal.  Thus  we  have 
positive  evidence  of  the  increased  production  of  the  solid  urinary 
constituents.  As  Formanek  and  others  have  shown,  there  is  an  in- 
creased elimination  of  nitrogen;  urea  is  excreted  more  abundantly; 
about  one-third  more  is  eliminated  on  the  day  of  the  bath,  and  this 
increased  elimination  continues  in  less  quantity  until  the  fifth  day. 
If  fluid  is  moderately  drunk  during  the  bath  the  increase  of  urea  is 
not  so  great  immediately  after  the  bath,  but  is  greater  during  the  five 
days  succeeding  it.  There  is  evidently  a  retention  of  urea  in  conse- 
quence of  insufficient  urinary  water,  but  the  average  for  the  six  days 
is  nearly  the  same,  whether  the  patient  drinks  water  or  not,  and 
affords  a  positive  measure  of  the  increase  of  tisssue  c/ianye.  The  uric- 
acid  excretion  produced  is  doubled  and  even  trebled  ;  it  is  greatest  in 
the  urine  passed  after  the  bath,  but  diminishes  rapidly  during  the 
succeeding  days.  The  quantity  of  sulphuric  and  phosphoric  acids  is 
also  decidedly  increased  during  and  after  the  hot-air  bath. 

Under  the  influence  of  hot-air  baths  a  decided  acceleration  of  oxi- 
dation of  nitrogenous  substances  (nutrient  and  tissue  albumin)  is  in- 
augurated, which  lasts  several  days.  Since,  however,  it  would  be 
impossible  to  maintain  an  increased  heat  supply  necessitated  by  the 


THE   HOT-AIR   BATH.  391 

continued  heat  diffusion  for  so  long  a  time,  an  increased  combustion  of 
fat  becomes  necessary.  This  is  entirely  in  accord  with  the  daily  obser- 
vation that  hot-air  baths  are  competent  to  produce  rapidly  a  very  con- 
siderable reduction  of  fat  in  persons  who  have  reduced  their  consump- 
tion of  fats  and  liquids.  Experiments  upon  animals  also  teach  this 
lesson.  Hence  we  possess  in  these  baths  a  means  of  inducing  and 
maintaining  a  considerable  acceleration  of  oxidation.  The  body  offers 
for  this  purpose  the  necessary  nitrogenous  and  non-nitrogenous  mate- 
rials (Frey). 

The  quantity  of  perspiration  produced  by  the  hot-air  bath  differs 
greatly  in  different  individuals  and  at  different  times.  Persons  who 
respond  feebly  to  the  first  bath,  requiring  prolonged  exposure  to  it,  and 
many  who  have  found  it  difficult  to  perspire  in  the  Turkish  baths,  be- 
come more  susceptible  to  the  hot-air  (cabinet)  bath  from  day  to  day. 
The  skin  appears  to  be  trained  to  better  action  by  its  daily  exposure  to 
high  temperature  followed  by  stimulating  douches  of  low  temperature. 

In  a  case  under  my  observation,  a  young  man  of  sixteen,  weighing 
one  hundred  and  eighty-eight  and  one-half  pounds,  with  a  girth  of 
thirty-eight  inches,  lost  three  and  one-half  pounds  during  the  first  hot- 
air  bath.  The  urea,  which  was  before  the  bath  six  grains  to  the  ounce, 
increased  to  eight  grains  to  the  ounce  in  the  urine  passed  after  the 
bath.  After  three  baths  there  was  a  total  loss  of  three  and  one-half 
pounds,  and  a  decrease  of  three  inches  in  the  girth,  so  that  his  trousers 
were  perfectly  loose.  Before  the  fourth  bath  he  had  gained  one  pound; 
after  the  fifth  bath  the  urea  was  eight  and  one-half  to  the  ounce. 

Therapeutic  Indications. — The  therapeutic  results  of  hot-air  baths 
may  be  deduced  from  its  rationale. 

Obesity,  chronic  rheumatism,  gout,  and  certain  cases  of  anosmia  offer 
indications  for  valuable  therapeutic  results  from  these  baths,  because 
tissue  change  is  enhanced  and  waste  products  are  oxidized  and  re- 
moved. The  enormous  changes  in  the  circulatory  activities,  with  their 
resultant  fluxions  and  added  supply  to  or  withdrawal  of  nutritive  ma- 
terial from  the  organs,  produce  changes  in  their  functions  which, 
judiciously  directed,  must  insure  to  the  patient's  advantage  in  these 
maladies. 

In  recent  myalgias  and  neuralgias,  lumbago,  and  other  forms  of 
muscular  rheumatism,  indeed  in  all  those  affections  for  which  the 
Turkish  bath  is  usually  prescribed,  the  hot-air  bath  as  here  described, 
carefully  observed  and  guarded  by  frequent  examination  of  the  patient, 
followed  with  douches  of  temperatures  judiciously  adapted  to  each 
case,  must  be  regarded  superior  in  value  and  extent  of  applicability 
to  the  empirically  used  Turkish  baths. 

In  syphilis,  when  the  system  has  been  saturated  by  mercury,  the 


392       THE   PRINCIPLES  AND   PRACTICE  OF   HYDROTHERAPY. 

elimination  of  which  is  desired,  we  have  a  valuable  eliminaut  in  the 
hot-air  bath.  The  experiments  of  Borovsky,*  showing  the  compara- 
tive value  of  various  baths,  prove  that  "  as  a  means  for  freeing  the 
patient's  system  from  mercury,  hot-air  baths  should  be  preferred  to  all 
other  baths  ;  hot-air  baths  at  170°-180°  of  twenty  minutes  are  borne 
better  than  those  at  140°-160°  of  thirty  minutes,  and  act  better  than 
hot- water  baths,  which  sometimes  give  rise  to  faintness  ;  hot-air  baths, 
by  inducing  intense  thirst,  increase  the  ingestion  of  liquids  and  then 
enhance  metabolism." 

The  superiority  of  the  hot-air  cabinet  bath  over  the  ordinary  Turkish 
bath  is  evident.  The  patient  is  surrounded  by  hot  air  in  the  cabinet, 
and,  the  head  being  free,  he  breathes  cooler  air.  Not  only  is  he  thus 
enabled  to  bear  higher  temperatures,  but  he  is  free  from  the  dyspnoea, 
which  is  so  distressing  to  many  in  the  hot-air  chamber  of  the  Turkish 
bath,  and  which  is  doubtless  due  to  a  defective  supply  of  oxygen;  the 
latter,  being  expanded  by  the  heat,  is  not  breathed  in  sufficient  quan- 
tity to  fulfil  its  physiological  function.  If  oxidation  be  the  chief 
object  of  the  hot-air  bath,  the  cabinet  bath  must  be  far  superior  to  the 
Turkish  bath,  because  its  temperature  permits  a  more  abundant  supply 
of  oxygen  and  thus  facilitates  oxidation.  Warm  air  contains  less  oxy- 
gen to  the  cubic  centimetre  than  does  cold  air.  The  volume  of  air  at 
the  disposal  of  the  lungs  is  about  one-eighth  larger  at  a  temperature 
of  70°  F.  (room  temperature)  than  at  130°  (Turkish-bath  tempera- 
ture). Besides,  the  patient  is  not  subjected  to  the  admixture  of  ema- 
nations from  the  large  number  of  persons  who  often  occupy  the  hot- 
air  chamber  simultaneously  in  the  Turkish-bath  establishments. 

Chronic  Rheumatism  and  Gout. — As  stated  in  the  chapter  devoted 
to  these  diseases,  the  hot-air  bath  is  chiefly  valuable  as  a  preparatory 
measure  to  hydrotherapeutic  procedures.  It  is  useful  in  those  cases 
which  are  characterized  by  obesity  and  plethoric  conditions,  for  the 
purpose  of  enhancing  tissue  change,  but  is  objectionable  by  reason  of 
overheating  the  blood.  Those  procedures  which  do  not  elevate  the 
bodily  temperature  so  much  as  prolonged  hot  baths  are  to  be  preferred. 

The  abuse  of  the  cabinet  home  treatment  needs  to  be  mentioned 
only  to  be  condemned.  They  are  sold  to  the  hapless  victims  with 
laudatory  commendation  ;  like  other  remedial  agents  of  intense  action, 
they  are  unsafe  in  the  hands  of  the  untrained.  Moreover,  the  patient 
may  receive  vastly  more  benefit  from  a  simple  hot  bath  intelligently 
executed  upon  the  physician's  prescription,  as  has  been  explained. 

*  British  Journal  of  Dermatology,  1889. 


CHAPTER  XXI. 

HYDROTHERAPEUTIC    APPARATUS    FOR    HOSPITALS,    ASYLUMS. 
AND  OTHER  INSTITUTIONS. 

HAVING  received  many  inquiries  from  hospitals,  insane  asylums, 
and  private  sanatoria,  with  regard  to  installation  of  hydrotherapeutic 
apparatus,  I  purpose  to  offer  an  outline  of  the  proper  construction  and 
arrangement  of  such  of  the  latter  as  I  have  devised.  This  may  serve 
to  further  the  systematic  use  of  water.  Such  institutions  being  under 
the  supervision  of  competent  physicians,  it  is  meet  that  the  latter  be 
thoroughly  informed  with  regard  to  the  best  arrangement  for  easily 
regulating  the  temperature,  duration,  pressure,  and  technique  of  the 
various  hydriatric  procedures. 

Two  kinds  of  institutions  exist,  the  rural  and  the  town  type.  The 
former  is  usually  situated  in  secluded  mountain  valleys,  surrounded  by 
beautiful  scenery  and  offering  the  benefits  of  seclusion,  removal  from 
unfavorable  environment,  and  systematic  regulation  of  the  patient's 
daily  life  and  habits.  This  is  the  best  type  of  hydrotherapeutic  estab- 
lishment. Unfortunately  these  are  rare  in  this  country  and  even  in 
Europe.  Although  hydrotherapeutic  institutions  abound  in  Europe, 
in  the  large  majority  there  is  too  much  routine  observed;  there  is  too 
much  of  the  old  hydropathic,  water-cure,  cure-all  spirit  pervading 
many  of  them.  Among  twenty-eight  institutions  visited  by  the  author 
in  the  summer  of  1896,  he  found  but  two  which  fulfilled  all  the 
demands  of  scientific  hydrotherapy.  This  is  not  written  in  a  captious 
spirit  nor  with  the  intent  to  convey  the  idea  that  good  work  is  not 
done  in  many — indeed  in  most — of  these  institutions.  But  the  best  work 
cannot  be  accomplished  when  there  are  no  facilities  for  positively  ascer- 
taining the  pressure  used,  by  the  "gauge;"  the  temperature  applied,  by 
the  thermometer ;  and  the  duration  by  a  proper  clock.  To  ascertain 
the  temperature  of  a  douche  by  the  attendant's  hand,  the  pressure 
from  the  assumed  height  of  the  reservoir  supplying  the  douche  room, 
and  the  duration  by  the  attendant's  experience  at  guessing  time,  such 
practice  is  not  sufficiently  accurate  to  obtain  the  best  results.  And 
yet  this  is  the  method  prevailing  at  many  of  the  institutions  referred  to. 
In  one  of  the  two  exceptions  mentioned,  the  gauge  truly  indicated  the 
pressure,  but  there  were  no  facilities  for  changing  the  latter  accurately, 
a  point  upon  which  I  have  sufficiently  insisted  in  the  preceding 
chapters. 

The  large  majority  of  cases  demanding  hydrotherapy  cannot  leave 


394       THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

their  home  and  families;  these,  too,  must  be  provided  for.  Domestic 
treatment  is  in  a  preponderating  number  quite  sufficient,  as  will  be 
shown  in  the  succeeding  chapters.  When  such  treatment  cannot  be 
obtained  at  the  hands  of  skilled  nurses,  or  when  the  physician  is  unable 
to  supervise  the  treatment,  either  for  want  of  time,  inclination,  or  imper- 
fect acquaintance  with  the  technique,  the  town  type  of  hydrotherapeu- 
tic  establishments,  conducted  by  a  physician,  fills  an  important  want. 
Here  the  patient  who  is  not.  too  seriously  ill  may  obtain  all  the  advan- 
tages of  a  thoroughly  equipped  institution,  without  being  deprived  of  the 
guidance  of  his  own  medical  adviser,  without  being  removed  from  family 
and  friends  (which  is  not  always  necessary),  and  without  sacrificing 
his  earning-capacity — a  very  important  consideration  in  many  cases. 

The  facilities  required  for  administering  water  in  the  various  pro- 
cedures may  be  arranged  in  a  small  compass.  There  is  no  absolute 
need  for  large  buildings.  A  space  of  thirty  by  one  hundred  feet  is 
abundant  for  all  practical  purposes,  and  may  be  made  to  accommodate 
fifty  patients  per  diem  easily. 

The  following  description  of  an  institution*  which  has  existed  for 
many  years  may  serve  as  an  example 

A  waiting-room  and  a  number  of  dressing-rooms  having  been  pro- 
vided, a  room  containing  two  or  more  cots  for  packs  is  set  aside,  and 
another  for  massage.  A  space,  twelve  feet  or  more  square,  is  utilized 
for  a  douche-room.  This  is  constructed  with  marble  walls  and  sup- 
plied with  ample  light  and  heat.  Above  a  waterproof  floor,  which 
slants  sufficiently  to  carry  water  into  a  pipe  leading  to  the  sewer,  a 
level  slatted  floor  is  laid  in  sections,  to  facilitate  removal  for  cleansing, 
in  such  a  manner  that  all  the  water  used  upon  patients  may  readily 
flow  through  the  interstices  between  the  slats  upon  the  waterproof 
floor  beneath.  Upon  the  upper  extremity  of  this  floor  a  circular  douche 
is  secured  (Fig.  68,  Cr).  Adjoining  this  a  large  bath  tub  and  sitz- 
bath  tub  is  placed,  the  latter  leaving  sufficient  space  to  admit  an  at- 
tendant behind  it.  The  douche  table  is  so  constructed  that  its  supply 
of  hot,  cold,  and  ice  water  is  sufficient  for  all  requirements  and  con- 
nected with  the  water  main. 

The  douche  table  (Fig.  68)  is  a  box  four  feet  long,  three  feet  high, 
and  two  feet  wide,  covered  with  marble.  Inclosed  within  the  box  is  a 
combination  of  pipes  connected  with  the  hot  and  cold  water  and  steam 
supply  on  the  one  hand,  and  with  the  hose  or  other  terminal  arrange- 
ment on  the  other. f  The  hot  and  cold  water  supply  is  by  the  usual 

*  The  Hydriatric  Institute,  635  Park  Avenue,  New  York. 

•(•  This  apparatus  has  been  in  successful  operation  during  the  past  ten  years  in 
the  following  institutions-  The  Riverside  Association;  St.  Elizabeth  (United 
States  Government)  Hospital,  Washington,  D.  C. ;  German  Hospital  of  Phila- 
delphia; McLane  Hospital,  Boston,  and  in  numerous  other  hospitals  and  sana- 
toria. 


HYDROTHERAPEUTIC   APPARATUS   FOR   HOSPITALS. 


395 


contrivance  controlled  by  stopcocks,  the  terminal  rods  and  levers  of 
which  issue  through  openings  in  the  upper  flat  portion  or  slab  of  the 
douche  table,  as  may  be  seen  in  the  diagram.  The  attendant,  stand- 
ing behind  this  table,  is  protected  against  receiving  the  -water  recoiling 
from  the  patient,  and  is  perfectly  free  to  regulate  the  outflow  accord- 
ing to  the  prescription  ordered  in  each  case.  An  outflow  pipe,  con- 
trolled by  the  stopcock,  PR,  regulates  the  pressure  of  the  water, 


FIG.  68.— Author's  Douche  Apparatus. 


Pfl,  Prescription  holder. 

S,  "Second  "  clock. 

H,  Hot  water. 

/,  Ice  water. 

C,  Cold  water. 

P,  Pressure  regulator. 


B.  Bell. 

6,  Gauffe. 

T,  Thermometer. 

R,  Rain  douche. 

O,  Circular  douche. 

C  J,  Cold  jet  douche. 


H  J,  Hot  jet  douche. 

H,  Hot  water  for  Scotch  douche. 

C,  Cold    water    for    Scotch 

douche. 
Hp,  Hip  bath. 
St,  Steam  douche. 


which  is  plainly  indicated  upon  the  gauge.  This  enables  the  attendant 
to  arrange  any  pressure  required,  either  before  the  douche  is  adminis- 
tered or  while  it  is  flowing  upon  the  body,  the  range  being  from  ten  to 
thirty-five  pounds.  The  importance  of  this  elemeni  in  hydrotherapy 
is  repeatedly  referred  to  in  this  work. 

A  thermometer,  T,  is  so  arranged  that  its  bulb,  encased  in  an  open- 
work metal  tube,  lies  within  the  mixer,  whose  outlet  pipe  leads  to  the 
hose,  and  its  upper  portion,  cased  in  metal  also,  shows  through  a  mag- 
nifying glass-tube  cover  the  temperature  of  the  water  flowing  upon  the 


396       THE  PRINCIPLES  AND  PRACTICE  OF  HYDROTHERAPY. 

patient.  A  "  second"  clock,  (7,  furnishes  information  regarding  dura- 
tion, while  the  clasp,  Cl,  holds  the  prescription  out  of  reach  of  the 
spray.  The  apparatus  is  put  into  operation  as  follows : 

The  attendant  places  the  prescription  into  the  clasp  after  carefully 
scanning  it,  and  opens  the  stopcocks  which  close  the  nozzle.  He  now 
opens  the  hot  and  cold  water  faucets,  and,  watching  the  thermometer, 
obtains  the  temperature  required  while  the  water  is  flowing.  This 
may  be  done  with  the  greatest  ease  after  some  practice.  He  now 
opens  the  pressure  regulator  until  the  gauge  registers  the  pressure 
prescribed.  The  attendant  having  examined  the  thermometer  again, 
and  holding  the  faucet  handle  in  the  left  hand,  while  the  right  holds 
to  one  side  the  proximal  part  of  the  metal*  (nozzle)  end  of  the  hose 
from  which  the  stream  of  water  is  issuing,  requests  the  patient  to  place 
himself  six  feet  in  front  of  the  douche  table.  Again  looking  at  the 
thermometer  to  insure  the  exact  temperature  prescribed,  he  now  directs 
the  stream  upon  the  patient's  back;  other  parts  are  treated  succes- 
sively as  ordered  by  the  physician.  If  a  circular  douche  is  ordered, 
the  water  is  also  turned  on  before  the  patient  enters  it.  This  is  im- 
portant, not  only  because  shock  is  thus  prevented,  but  timidity  of  the 
patient  is  overcome  if  the  patient  sees  the  water  flowing. 

The  circular  douche  used  in  the  Hydriatric  Institute  differs,  as  the 
diagram  shows,  from  the  usual  needle  bath,  in  not  being  supplied  with 
semicircular  perforated  pipes.  I  found  the  effect  greatly  enhanced 
and  much  trouble  from  stoppage  avoided  by  the  substitution  of  eight 
roses,  three  inches  in  diameter.  Each  rose  contains  fifty  fine  openings 
in  the  plate,  which,  being  screwed  on  to  the  connecting-tube,  may  thus 
be  easily  freed  from  accumulating  sand  and  dirt.  Moreover,  the  three 
upper  roses  are,  by  a  device  of  Mr.  Frank  Eichter,  the  excellent 
mechanic  who  has  skilfully  executed  all  my  ideas,  made  movable.  By 
simply  turning  these  roses  downward,  an  adult  of  any  height  may  be 
treated  without  having  the  face  sprinkled  or  the  eajs  filled  with  water. 

The  douche  table  contains  pipes,  the  outlets  of  which  are  controlled 
by  lever  faucets,  which  also  open  and  close  the  perineal  douche,  the 
hip  bath,  and  the  full  bath.  The  temperature  of  these  may  thus  be 
controlled  by  the  attendant  by  simply  watching  the  thermometer  of  the 
douche  table. 

There  is  also  a  steam  douche,  supplied  with  low-pressure  steam, 
which  may  be  made  to  issue  from  the  hose  by  opening  the  faucet  St. 
Steam  must  be  free  of  water  to  avoid  scalding,  and  its  dry  flow  insured 
before  the  patient  exposes  himself  to  the  douche. 

*  By  always  holding  the  hose  at  its  metallic  extremity,  the  attendant  is 
warned  if  the  temperature  of  the  water  flowing  through  it  is,  by  reason  of 
any  inadvertence  in  the  reading  of  the  thermometer  or  other  cause,  too  high 
or  too  low.  Thus  damage  to  the  patient  may  be  easily  averted. 


HYDBOTHERAPEUTIC  APPARATUS  TOR  HOSPITALS.  397 

The  douche  room  of  the  Hydriatric  Institute  is  twelve  feet  long  and 
eight  feet  wide,  its  walls  being  covered  with  marble  eight  feet  high. 
The  floor  of  this  compartment  is  slanting  and  covered  with  copper; 
the  edges  of  the  latter  are  secured  by  being  turned  up  two  inches  behind 
the  lower  edge  of  the  marble  wall.  Beams  cut  slanting  on  the  lower 
side  to  fit  the  watertight  floor,  and  straight  on  the  upper  side,  are  laid 
horizontally,  so  as  to  support  a  slatted  floor,  through  which  all  the 
water  flows  upon  the  copper  beneath  and  thence  to  the  sewer.  The 
materials  must  be  of  the  best  quality,  to  avoid  leaks. 

The  perineal  douche  is  obtained  by  leading  a  pipe  connected  with 
the  hot  and  cold  water  supply  in  the  douche  table  to  a  point  three  feet 
from  the  latter,  adjoining  the  hip  tub.  Over  this  is  placed  a  box  or 
chair,  twenty-five  inches  high,  having  a  circular  opening  to  admit 
the  perineum.  The  stream  emerging  from  below  may  thus  be  made 
to  strike  the  perineum  under  any  re- 
quired degree  of  pressure  and  at  any 
required  degree  of  temperature. 

The  water  supply  comes  from  a 
reservoir  (under  the  roof),  to  which 
it  is  pumped  by  a  steam  engine.  The 
hot  water  is  furnished  from  a  drum 
which  is  heated  by  steam  coils.  Both 
cold  and  hot  water  flow  through  ap- 
propriate pipes  to  the  douche  table; 
and  ice  water,  which  is  required  in 
summer,  is  furnished  by  a  cooling-ap- 
paratus constructed  as  follows :  In  the 
basement,  occupied  as  a  laundry,  is 
situated  a  box,  seven  by  five  feet  and 
four  feet  high,  which  has  double  walls 
four  inches  apart.  A  manhole,  two 
and  one-half  feet  square  on  top,  ad- 
mits of  ice  being  thrown  in.  The  box 
is  lined  with  copper,  so  as  to  be  water- 
tight. At  the  bottom  two  boards,  FIG.  «9. -Perineal  Douche, 
two  inches  thick  and  one  foot  deep,  are  placed  from  one  side  to  the 
other.  These  have  three  semicircular  notches,  fitting  three  galvanized 
iron  cylinders,  for  which  they  form  a  support  (Fig.  70). 

The  cylinders  contain  thirty  gallons  each  and  are  connected  with 
each  other  by  inch  pipes.  The  first  cylinder  receives  the  water 
supply  from  a  two-inch  main.  The  water  entering  this  cylinder  passes 
to  the  second,  thence  at  the  opposite  end  to  the  third,  from  which  it 
issues  into  an  inch  pipe  leading  to  the  douche  table  in  the  room  above. 
Six  inches  above  the  level  of  the  cylinders  an  inch  opening  exists, 
which  is  connected  with  an  outflow  pipe  connected  with  the  sewer. 


398        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

A  separate  pipe,  supplied  with  a  stopcock,  should  also  lead  from  the 
main  directly  into  the  box,  for  the  purpose  of  filling  the  latter  with 
water  as  high  as  the  outlet  above  the  level  of  the  cylinders. 

The  box  is  elevated  about  one  foot  from  the  floor,  and  an  out- 
flow pipe  with  stopcock  should  be  securely  connected  with  the  latter 


and  lead  to  the  sewer,  for  the  purpose  of  emptying  the  box  when 
necessary. 


HYDROTHERAPEUTIC   APPARATUS   FOR   HOSPITALS.  399 

The  apparatus  is  prepared  as  follows :  The  stopcock  of  the  pipe  A, 
leading  from  the  main,  is  opened  for  the  purpose  of  filling  the  cylinders ; 
the  stopcock  C,  at  the  bottom  of  the  box,  being  closed,  the  stopcock  S 
is  opened  and  water  is  allowed  to  flow  into  the  copper-lined  box  until 
the  cylinders  are  covered  with  water,  six  inches  deep.  Now  half  a 
ton  of  ice  is  put  upon  the  cylinders.  It  will  be  observed  that  the  lower 
portion  of  the  ice  supply  lies  in  six  inches  of  the  water  which  covers 
the  cylinders.  Thus  the  latter  are  not  only  covered  by  ice  but 
surrounded  by  ice  water.  As  the  ice  melts  the  overflow  of  water 
issues  through  the  opening  X  to  the  stopcock  D,  which  is  always  left 
open. 

After  experiments  with  ice  placed  upon  slats  above  the  cylinders, 
and  thus  surrounding  them  below  with  cold  air,  I  find  the  apparatus 
described  above  the  most  practical  means  for  cooling  water. 

The  necessity  for  this  ice-water  supply  will  be  evident  when  it  is 
borne  in  mind  that  in  midsummer,  when  the  Croton  water  ranges  from 
70°  to  80°,  a  prescription  for  a  douche  of  50°  to  60°  could  not  be  filled 
without  such  a  supply.  It  is  necessary  only  to  open  the  ordinary  cold- 
water  supply  cock  and  add  as  much  ice  water,  by  opening  the  ice- 
water  supply  cock,  as  is  needed  to  reduce  the  former  to  the  tem- 
perature prescribed.  I  am  not  aware  of  the  existence  of  a  similar 
combination  apparatus  for  exact  hydrotherapy  in  any  institution  in 
Europe  or  in  this  country,  except  those  of  the  Montefiore  Home,  the 
German  Hospital  in  Philadelphia,  the  Massachusetts  State  Asylum  at 
Danvers,  the  United  States  Government  Asylum  (Elizabeth)  in  Wash- 
ington, and  others  constructed  under  my  advice.  At  some  of  the 
water-cure  establishments  which  I  have  visited  in  Germany  and  else- 
where, such  an  arrangement  is  unnecessary,  because  the  mountain 
springs  furnish  water  at  very  low  temperatures,  50°  being  quite  fre- 
quent. 

The  hot-air  cabinets  are  a  very  important  part  of  the  hydrotherapeutic 
apparatus.  They  are  used  for  the  purposes  previously  indicated. 
They  are  made  of  thoroughly  seasoned  wood,  shaped  as  shown  in  Tig, 
72,  and  constructed  v/ith  movable  tops  and  doors.  An  adjustable  seat 
is  securely  installed  within.  The  heat  is  supplied  by  steam  coil  radi- 
ators and  the  temperature  is  ascertained  by  a  thermometer,  the  bulb  of 
which  rests  within  the  box,  while  the  indicator  is  above  it.  A  circular 
opening,  0,  in  the  stationary  and  movable  portion  of  the  top  of  the 
box  admits  the  neck.  The  patient,  enveloped  in  a  sheet,  seats  himself, 
allowing  his  head  to  project,  presenting  the  appearance  shown  in  Fig. 
71.  A  large  towel  is  placed  around  his  neck  in  such  manner  that  it 
covers  the  open  space  between  the  neck  and  the  edge  of  the  opening. 

The  head  is  swathed  in  a  wet  turban  and  the  patient  receives  water 
from  the  attendant  as  often  as  it  is  ordered  by  the  physician.  Bright 


400        THE   PRINCIPLES  AND   PRACTICE   OF   HYDRO-THERAPY. 

sunlight  and  flowers  contribute  to  the  cheerfulness  of  this  room  in 
which  the  patient  is  prepared  for  water  treatment  (Fig.  72).  After  the 
doucheur  has  turned  on  water  at  the  prescribed  temperature,  he  touches 
the  bell,  B,  which  announces  his  readiness  to  receive  the  patient. 
The  latter  is  now  to  emerge  from  the  box,  which  has  been  opened 
by  another  attendant  upon  being  informed  by  the  bell.  He  drops 


FIG.  71.— Hot-Air  Box— Open. 

the  warm  sheet  which  has  enveloped  him  and  places  himself  before 
the  doucheur;  after  he  has  received  his  douche  he  comes  forward,  the 
warm  sheet  is  thrown  over  him,  and  he  is  carefully  dried,  standing  or 
sitting.  He  now  retires  to  his  dressing-room,  makes  his  toilet,  and 
immediately  goes  forth  into  the  fresh  air.  The  latter  is  usually 
insisted  upon,  although  many  patients  cannot  be  rid  of  the  idea  of 
"  resting  after  the  bath, "  which  they  have  derived  from  their  experience 


HYDROTHERAPEUTIC   APPARATUS   FOR   HOSPITALS.  401 


26 


402       THE   PRINCIPLES  AND   PRACTICE  OF   HYDRO-THERAPY. 

in  "Turkish  baths."  Inasmuch  as  the  patient  has  not  inhaled  hot 
air  and  his  reaction  is  fully  established,  it  is  far  better  for  him  to  issue 
forth  into  the  street  or  park  and  obtain  the  full  benefit  of  the  deepened 
inspiration. 

Among  the  records  of  several  hundred  thousand  treatments,  "  con- 
tracting a  cold  "  is  rarely  traceable  as  an  effect.  Even  in  midwinter 
the  poorest  clad  persons  leave  the  clinic  after  the  most  active  perspira- 
tion (eliminative)  treatment,  for  the  street. 

For  this  reason  I  have  always  counselled  those  who  consult  me  with 
regard  to  space  and  arrangement  of  institutes  for  hydrotherapy,  to 
avoid  "resting-rooms."  These  are  unnecessary,  indeed  harmful,  be- 
cause the  patient  becomes  relaxed  in  the  usually  hot  and  ill- ventilated 
apartment  The  close  proximity  of  a  number  of  patients,  resting  in 
this  luxurious  fashion,  also  promotes  discussions  of  ailments  and  of  the 
treatment  which  may  react  unfavorably  on  the  psychic  side  of  the  case. 
Moreover,  the  cost  of  large  space  needed,  and  of  furnishings  for  such 
a  room,  is  large  and  absolutely  needless. 

The  simple  apparatus  above  described  enables  the  physician  to  have 
every  prescription  for  baths  and  douches  executed.  The  temperature 
may  be  easily  and  quickly  regulated  to  each  degree,  the  pressure  to 
each  pound.  Thus  the  utmost  precision  may  be  practised  by  means 
of  this  compact  arrangement  of  pipes,  faucets,  and  hose. 

The  small  number  of  ambulant  cases  usually  cared  for  in  the  gen- 
eral hospitals  does  not  warrant  the  expenditure  required  for  a  complete 
hydrotherapeutic  apparatus,  except  for  their  outdoor  departments. 


CHAPTEE   XXII. 

CHRONIC  DISEASES. 

THOSE  diseases  in  which  nutrition,  heematosis,  and  tissue  change 
are  disturbed  afford  a  favorable  field  for  the  remedial  application  of 
water.  The  chapter  on  "  The  Influence  of  Hydriatric  Measures  upon  the 
Functions  of  the  Human  Organism"  points  out  clearly  the  effect  of 
water  applications  in  health,  as  ascertained  by  reliable  laboratory  ex- 
periments and  observations.  The  application  of  these  physiological 
effects  in  chronic  disease  will  form  the  subject  of  the  following  chapters. 

ANAEMIA  AND  CHLOROSIS. 

These  affections  are  grouped  together,  because  they  present  similar 
manifestations  arising  from  imperfect  hsematosis.  To  enter  into  the 
symptoms  and  causes  of  these  disturbances  is  not  the  province  of  this 
work.  A  few  introductory  remarks  may  afford  an  insight  into  the 
rationale  of  the  action  of  hydrotherapy  in  these  diseases,  and  the 
necessity  of  combining  them,  as  is  always  indicated,  With  a  strict 
hygiene. 

Whether  it  be  idiopathic  or  a  manifestation  of  organic  pathological 
processes,  a  faulty  hsematosis  frequently  demands  the  attention  of  the 
physician.  The  patient  and  his  friends  are  justly  anxious  when  pallor, 
accompanied  or  not  by  emaciation,  points  with  unerring  finger  to  some 
serious  defect  in  the  system.  The  remedies  usually  applied  with  more 
or  less  energy  are  nutritious  diet,  exercise,  change  of  scene,  and  iron. 
Months  and  years  are  sometimes  spent,  with  more  or  less  success,  in 
the  treatment  of  failing  heematosis.  Of  how  little  avail  are  a  nutritious 
diet  and  iron  if  the  appetite  is  feeble  and  the  stomach  incapacitated 
is  a  sad  but  frequent  observation  of  the  experienced  practitioner. 

In  mild  cases  of  functional  anaemia,  due  to  overwork,  inattention 
to  sanitary  conditions,  insufficient  food,  or  mental  disturbance,  the  re- 
moval of  the  cause  is  the  chief  end  of  treatment.  But  these  may  be 
powerfully  aided  by  certain  hydriatric  procedures,  whose  effect  has 
been  demonstrated  to  improve  the  force  of  the  heart,  deepen  the  respi- 
ration, and  enhance  tissue  metabolism.  That  water  of  low  tempera- 
ture, rapidly  and  briefly  applied  under  good  atmospheric  pressure, 
produces  these  effects,  clinical  observation  has  frequently  demon- 


404       THE  PRINCIPLES  AND  PRACTICE   OF   HYDROTHERAPY. 

strated.  The  result  of  careful  examination  with  the  microscope  and 
haemometer  demonstrates  that  the  judicious  application  of  cold  to  the 
periphery  increases  the  number  of  red  corpuscles  and  improves  their 
quality. 

The  necessity  of  promoting  and  encouraging  tissue  change  in  all 
diseases  in  which  there  is  faulty  haematosis  is  obvious.  There  exists 
abundant  testimony  as  to  the  auxiliary  value  of  hydrotherapy.  Again 
and  again  I  have  observed  cases  of  anaemia  and  chlorosis,  which  had 
defied  prolonged  iron  treatment  under  my  own  care  as  well  as  under 
the  advice  of  colleagues,  yield  readily  when  a  suitable  hydriatric  method 
was  added  to  or  substituted  for  it. 

Upon  the  recognition  of  the  etiology  of  anaemia  depends  its  success- 
ful treatment.  So  long  as  anaemia  remains  associated  with  iron 
treatment  in  the  minds  of  physicians,  so  long  will  its  management 
remain  unsatisfactory. 

1.  Unfavorable  environment  is  a  frequent  cause  contributing  to  the 
development  of  anaemia.  Confinement  to  badly  ventilated  schoolrooms, 
deprivation  of  outdoor  exercise,  digestive  troubles  due  to  these,  im- 
proper and  insufficient  food,  and  mental  anxiety  are  recognized  factors. 
Of  what  avail  would  the  administration  of  iron  be  in  such  cases  so  long 
as  these  etiological  elements  are  active?  Of  what  use  would  an  addi- 
tion of  iron  to  the  haemoglobin  be  if  its  hunger  for  oxygen  cannot  be 
appeased  by  exposure  of  the  patient  to  pure  air?  I  would  plead,  there- 
fore, first,  for  the  provision  of  an  ample  supply  of  oxygen  for  anaemic 
patients ;  not  oxygen  artificially  made  and  forced  into  the  lungs,  but 
oxygen  obtained  in  the  only  perfect  form — from  natural  sources,  in  the 
fields,  in  the  woods,  in  the  parks,  freed  from  human  emanations,  which 
contaminate  it  even  in  the  better  class  of  city  and  town  dwellings. 
Those  who  have  done  much  dispensary  practice  will  agree  that  among 
the  patients  of  the  tenement  districts  iron  is  particularly  unsuccessful. 
The  latter  is  also  true  of  schoolgirls  and  boys,  who  are  subjected  to 
continuous  Study  and  are  thus  deprived  of  access  to  pure  air  and  nms- 
cular  exercise.  The  lesson  taught  by  common  sense  would  be  to  re- 
move the  patient  from  his  unfortunate  surroundings  rather  than  to  ply 
him  with  medicinal  agents  to  improve  his  blood.  Severe  anaemics 
among  the  poorer  classes  must  be  brought  to  the  hospital ;  here  at  least 
the  air  is  pure,  and  other  important  agencies  of  restoration  are  avail- 
able. It  is  surprising  how  such  a  change  brings  back  the  color  to  the 
pallid  cheek  of  the  factory  girl  and  the  store  clerk.  Though  they  may 
not  be  ill  enough  to  have  life  threatened,  these  poor  creatures  are  en- 
titled to  the  same  care  as  is  a  case  of  typhoid  or  pneumonia.  A  few 
weeks'  residence  in  a  clean,  well-aired  hospital  ward  will  do  more  to 
restore  such  patients  to  health  than  iron  or  arsenic  alone. 


CHRONIC   DISEASES.  405 

I  desire  to  emphasize  also  the  inutility,  nay,  the  impropriety,  of 
advising  active  exercise  for  every  case  of  anaemia.  Too  often  the 
direction  is  given  to  the  anaemic  who  is  in  good  financial  circumstances : 
take  plenty  of  exercise,  good  food,  and  (iron)  pills  three  times  a  day. 
Many  patients,  especially  those  who  suffer  from  dyspnoea  and  rapid 
heart  action,  would  be  more  improved  by  being  exposed  for  hours  in 
the  open  air,  quite  at  rest,  in  a  hammock  in  summer,  or  on  a  steamer 
chair  wrapped  in  furs  or  blankets  in  winter,  with  the  windows  thrown 
wide  open. 

Passive  exercise  by  massage  and  Swedish  movements  once  or  twice 
a  day  would  be  far  more  valuable  exercise  than  walking  or  even  riding. 
Mary  Putnam  Jacobi  has  by  careful  observation  brought  out  the  value 
of  massage  in  anaemia,  and  Weir  Mitchell  has  demonstrated  the  import- 
ance of  rest  combined  with  massage  and  food,  methodically  adminis- 
tered. Their  success  after  failure  of  active  exercise  and  medication 
vouches  for  the  correctness  of  the  view  here  inculcated. 

2.  Systematic  exercise  in  the  open  air  may  be  useful  in  many  cases. 
Special  stress  must  be  laid  upon  the  adjective  "  systematic."     Let  the 
direction  for  exercise  be  as  precise  as  it  usually  is  given  for  pills ;  let 
the  duration,  variety,  and  frequency  of  repetition  be  distinctly  ordered. 
Ranke  has  investigated  the  effect  of  muscular  action  upon  the  total 
blood  in  the  body.     He  has  shown  that  its  first  effect  is  diminution  of 
the  blood  quantum,  which  becomes  more  marked  as  the  intensity  of  the 
muscular  action  increases ;  but  when  the  body  becomes  accustomed  to 
active  exertion  the  total  blood  quantum  is  increased.     Thus  is  phy- 
siologically demonstrated  the  great  benefit  of  methodical  exercise,  and 
especially  the   necessity  of   adapting  it  to  each  individual  case   of 
anaemia. 

3.  Diet — The  adaptation  of  a  proper  diet  to  anaemia  is  not  a  diffi- 
cult problem.     I  plead  only  for  more  punctilious  regard  to  the  needs 
of  each  case  than  is  usually  given.     The  fancies  and  caprices  of  the 
patient  should  be  less  regarded  than  is  the  practice  now,  for  many 
articles  of  food  that  seem  repugnant  to  the  patient  may  be  gradually 
administered  if  a  good  nurse  is  instructed  to  persist  in  their  systematic 
use.     Weir  Mitchell  has  in  this  respect  taught  us  a  lesson  also.     Many 
patients  who  were  absolutely  without  appetite,  and  to  whom  all  food 
was  repugnant,  have  been  systematically  fed  by  properly  selected  atten- 
dants until  the  quantity  consumed  by  them  was  enormous.     We  yield 
too  easily  to  the  predilections  of  the  patient  in  this  regard.     It  must 
be  borne  in  mind  that  usually  all  appetite  is  lost  or  impaired,  ar  d  that 
therefore  a  choice  of  acceptable  food  is  impossible. 

Careful  attention  to  methodical  feeding  will  accomplish  more  than 
simple  direction  to  take  good  food,  etc.  The  same  precision  which  is 


406        THE   PRINCIPLES   AND   PRACTICE    OF   HYDRO-THERAPY. 

exercised  in  ordering  medicines  will  in  the  case  of  diet  produce  more 
positive  results  than  are  usually  obtained. 

4.  Water. — In  connection  with  the  methodical  application  of  pure 
air,  exercise,  and  food,  the  use  of  water  upon  the  skin  is  important.  I 
do  not  advocate  cold  baths  for  anaemic  patients,  nor  indeed  for  any 
patient  except  one  suffering  from  an  infectious  fever.  The  abstraction 
of  heat  should  be  always  avoided  in  anaemia.  It  is  my  custom  to  pro- 
duce an  artificial  surface  heat  before  applying  cold  water.  If  the 
latter  is  done  just  after  rising  from  bed,  it  will  in  many  cases  be  suffi- 
cient. While  standing  in  a  tub  of  water  at  100°,  the  temperature  of 
the  room  being  not  below  68°,  the  patient  receives  a  rapid  ablution, 
with  friction,  of  water  at  80°,  which  is  daily  reduced  two  or  three  de- 
grees. After  this  he  is  rapidly  dried  and  induced  to  go  into  the  open 
air.  For  weaker  patients  the  dry  pack,  which  is  simply  a  snug  wrap- 
ping in  a  woollen  blanket  until  they  are  warm,  followed  by  ablution  as 
here  stated,  is  useful.  The  abstraction  of  heat  may  be  guarded  against 
and  chilliness  prevented  by  accumulating  heat  on  the  surface  before  the 
ablution. 

When  the  cutaneous  surface  has  thus  been  daily  disciplined  and 
educated  to  bear  the  gentle  shock  from  gradual  impingement  of  cold 
water,  larger  quantities  may  be  used.  The  dripping-sheet,  so  highly 
commended  by  Weir  Mitchell;  the  wet  pack,  followed  by  the  half- 
bath;  and  later  rain  baths  and  jet  douches  judiciously  adapted  to  each 
case,  offer  the  most  valuable  means  for  restoring  the  blood  to  its 
normal  condition.  Actual  examination  with  Fleischl's  haemometer  has 
convinced  me  of  this  therapeutic  fact. 

I  treated  a  young  lady  who  had  taken  six  hundred  Blaud  pills  with- 
out the  slightest  effect.  She  received  twelve  rain  baths  and  steadily  im- 
proved in  color,  strength,  and  ability  to  exercise  without  breathlessness. 

The  presence  of  organic  disease  does  not  preclude  the  application 
of  hydrotherapy.  This  is  amply  demonstrated  by  its  effective  appli- 
cation in  cardiac,  renal,  hepatic,  uterine,  and  nervous  diseases.  What- 
ever tends  to  elevate  the  general  tone  of  the  system,  stimulate  the 
appetite,  heighten  the  nutrition,  give  sleep,  and  refresh  the  body, 
is  of  value  in  cases  of  organic  disease.  We  have  ample  warrant  for 
asserting  that  the  cautious  application  of  water  has  no  equal  in  these 
therapeutic  qualities.  Frequently  the  domestic  treatment  by  a  skilled 
nurse  suffices  to  establish  normal  hsematosis.  This  failing,  however, 
a  large  and  fruitful  resource  is  open  in  institutional  treatment. 

The  following  clinical  history  furnishes  a  detailed  outline  of  the 
most  useful  procedures,  which  may  be  varied  to  adapt  them  to  each 
case,  if  the  principles  and  technique  have  been  mastered. 

Miss  H ,  aged  twenty,  ill  two  years,  under  constant  treatment  by  gynaecolo- 


CHEONIC  DISEASES.  407 

gists  in  Harrisburg,  Baltimore,  and  Philadelphia,  was  brought  as  a  last  resort  to 
Dr.  T.  G.  Thomas,  to  be  placed  in  his  sanatorium.  Dr.  Thomas  discovered  no 
uterine  trouble,  and  referred  her  on  June  8th,  1892,  for  hydriatic  treatment,  with 
a  diagnosis  of  chlorosis  of  aggravated  type.  Local  and  medicinal  and  institution 
treatment,  iron,  arsenic,  diet,  and  massage  and  change  of  air,  had  been  tried 
in  vain  by  physicians  in  Philadelphia  and  Harrisburg,  Penn.  Although  the 
patient  was  plump,  a  more  pallid  creature  could  not  be  imagined.  Her  appetite 
was  poor,  her  bowels  were  irregular,  her  sleep  was  disturbed,  and  she  was  subject 
to  frequent  (hysterical)  fainting  spells.  The  slightest  exertion  produced  difficult 
breathing  and  rapid  heart  action.  The  menstrual  flow  was  regular,  but  scant 
and  very  pale.  Blood  examined  by  Fleischl's  hsemometer  registered  thirty-one 
per  cent. 

June  10th.  Preparatory  treatment  by  hot-air  baths  and  spray  douche,  to  edu- 
cate the  patient's  reactive  capacity,  was  ordered.  Fainting  in  the  hot-air  bath, 
she  was  removed.  A  spray  douche  of  two  seconds  at  64°,  with  twenty  pounds' 
pressure,  was  rapidly  passed  over  her  in  a  sitting-posture.  She  again  fainted. 
Friction  produced  no  reaction. 

On  the  following  day  a  milder  course  was  pursued.  She  was  gently  wrapped 
in  a  long-haired  woollen  blanket  for  forty-five  minutes.  Parts  of  the  body  were 
then  successively  uncovered  and  splashed  with  water  at  60°,  thrown  with  some 
force  from  the  hollow  hand  of  the  attendant.  This  was  followed  by  friction,  and 
continued  until  the  whole  body  had  received  the  ablution  and  friction.  The  same 
treatment  was  continued  on  the  12th  and  13th,  when  she  fainted  twice.  This 
was  repeated  without  fainting  until  the  16th  of  June.  She  was  now  placed  in 
a  hot-air  bath  (167°),  with  a  cold  compress  around  the  head,  and  given  frequent 
sips  of  ice  water.  The  head  not  being  subjected  to  the  heat,  the  patient  was 
enabled  to  breathe  the  cool  air  of  the  room.  When  the  cutaneous  surface  became 
tinged,  she  was  seated  in  a  tub  containing  eighteen  inches  of  water  at  100°,  and 
thoroughly  rubbed  for  three  minutes.  This  was  followed  by  an  ablution  at  60°, 
good  friction  drying,  and  general  massage  for  fifteen  minutes.  She  fainted 
twice  during  these  procedures. 

June  20th.  The  hot-air  bath  followed  by  the  spray  (fan)  douche  at  80°  was 
substituted  for  the  ablution,  because  her  reaction  had  improved  and  her  timidity 
had  diminished. 

July  8th.  The  last  treatment  has  been  continued  with  satisfactory  results, 
temperature  of  the  spray  douche  reduced  daily  one  degree ;  to-day  she  had  an 
air  bath  (160°  F.),  followed  by  a  spray  douche  under  thirty  pounds'  pressure  for 
five  seconds,  beginning  at  80°  and  rapidly  reduced  to  50°,  followed  by  fifteen 
minutes'  general  massage.  She  reacted  well  and  felt  comfortable. 

July  14th.  Hot-air  bath  (175°) ,  followed  by  a  circular  douche,  thirty  seconds, 
at  94°  reduced  to  69° ;  then  spray  douche,  ten  seconds,  79°  to  54°,  and  general 
massage.  Reaction  good. 

July  30th.  Hot-air  bath  followed  by  circular  douche  of  95°  and  a  jet  douche 
at  45°.  That  she  bore  the  latter  without  flinching  testifies  to  the  value  of  gradually 
accustoming  the  patient  to  lower  temperatures.  Dr.  S.  T.  Armstrong,  who  ex- 
amined her  for  me,  reports  :  "MissH.  looks  quite  well,  eats  and  sleeps  well,  and 
is  certainly  improved  since  I  last  saw  her.  The  comparison  test  indicates  about 
one  hundred  per  cent,  haemoglobin.  " 

Miss  H.  is  now  married  and  in  good  health. 

This  case  certainly  illustrates,  first,  the  effect  of  the  douche  in  im- 
proving the  nutrition ;  second,  that  haematosis  may  be  enhanced  by  the 


408       THE   PRINCIPLES   AND    PRACTICE   OF    HYDROTHERAPY. 

stimulus  conveyed  from  the  periphery  to  the  nerve  centres,  and  thus 
reflected  upon  the  blood-making  functions ;  third,  that  the  most  feebly 
reacting  patient  may,  by  perseverance  and  proper  adaptation  of  the 
hydriatric  procedures,  become  accustomed  to  this  treatment.  The 
danger  of  shock  from  cold  water  is  proven  to  be  chimerical  by  this 
case.  If  this  fragile  and  sensitive  young  woman  could  be  accustomed 
to  the  douche  by  beginning  with  mild  procedures,  no  chronic  case  that 
is  not  in  extremis  could  fail  to  respond  to  it. 

5.  Diaphoresis  is  a  method  of  treatment  which,  paradoxical  as  it 
may  seem,  has  demonstrated  its  value  clinically.  Scholz,  of  Bremen, 
has  written  a  monograph  on  this  subject;  his  conclusions  have  been 
extensively  reproduced  in  the  medical  journals  and  his  practice  has 
found  imitation.  The  dry,  livid  condition  of  the  skin  of  anaemic  pa- 
tients is  aroused  to  renewed  activity  by  exposure  to  hot-air  baths. 
Excretion  is  thus  rendered  more  energetic,  tissue  change  is  enhanced, 
and  an  increase  of  appetite  and  nutrition  is  thus  induced. 

It  is  my  constant  practice  to  order  for  anaemic  patients  one  or  more 
thorough  diaphoretic  (hot-air)  baths  a  week,  followed  by  gradually 
reduced  douches,  for  the  purpose  of  overcoming  the  spastic  contraction 
of  the  arterioles  and  enhancing  tissue  change,  and  thus  improving  as- 
similation of  albuminoids. 

Prof.  0.  Eosenbach*  correctly  insists  that,  "  in  order  really  to  cure 
chlorotics,  control  of  the  vasomotor  neurosis  which  exist  in  these  cases 
must  be  obtained,  and  in  order  that  this  may  be  accomplished  by  hydri- 
atic  procedures  great  care  should  be  taken  in  thsir  employment ;  they 
must  be  brief  and  used  only  when  the  corpuscles  are  not  greatly  dimin- 
ished. Judicious  hydrotherapy  not  only  removes  this  disease,  but  also 
prevents  the  relapses  which  are  so  frequent.  Dr.  Eosenbach  does  not 
pretend  that  hydriatic  treatment  only  is  capable  of  influencing  the 
vasomotor  centres  and  completely  curing  chlorosis,  for  many  chlorotics 
do  recover  without  hydrotherapy.  Nevertheless,  it  is  proven  that  iron, 
arsenic,  country  air,  the  gratifications  of  ardent  desires,  pregnancy, 
etc. — i.e.,  all  influences  which  are  capable  of  influencing  chlorosis 
favorably — do  so  by  modifying  centripetal  vasomotor  irritation  or  by 
restoring  normal  conditions  in  the  vasomotor  centres  rather  than  by  re- 
constructing blood  cells  and  plasma." 

For  the  restoration  of  normal  condition  in  the  innervation,  experi- 
ence has  demonstrated  the  exceeding  value  of  hydriatric  procedures. 

Whatever  the  rationale  may  be,  this  treatment,  together  with 
systematic  regulation  of  diet,  exercise,  and  exposure  to  good  air,  has 
in  my  hands  often  been  crowned  with  success  after  failure  of  medicinal 
agents. 

*  Internationale  Klinische  Rundschau,  1894,  p.  877. 


CHAPTER  XXIII. 

PHTHISIS. 

THE  hygienic  management  of  phthisis  has  in  recent  years  afforded 
such  striking  results  that  this  method  has  attained  the  first  rank 
among  therapeutic  agents.  The  search  after  specifics  still  continues, 
and  should  be  encouraged,  because  this  fearful  scourge  has  always 
been  an  opprobrium  medicorum.  The  possibility  of  obtaining  a  prepa- 
ration which  represents  nature's  antitoxin  is  still  entertained,  and  not 
without  reason.  In  the  mean  time  the  fatality  of  the  disease  remains 
unabated  among  those  people  who  are  unable  to  obtain  the  hygienic 
management  which  is  so  costly  that  an  experienced  observer  has  ven- 
tured the  opinion  that  "  the  question  of  cure  of  phthisis  is  a  question  of 
money  chiefly." 

That  phthisis  is  often  cured  has  been  demonstrated  satisfactorily. 
The  most  recent  authorities  confirm  the  statement  contained  in  the  report 
of  the  royal  health  office  of  Germany  on  "  Hospitals  for  Consumptives." 
"Evidence  of  healed  tuberculous  lesions  is  often  seen  by  experi- 
enced pathological  anatomists;  not  only  do  one-half  of  all  subjects 
dying  of  tuberculosis  show  old  scars  of  tuberculous  lesions,  but  even 
among  those  who  have  died  of  other  diseases,  or  in  the  full  bloom  of  health 
by  accident  or  suicide,  these  scars  are  often  found.  According  to  reliable 
authorities,  healed  tuberculous  foci,  encapsulated  or  calcified,  are  found 
in  every  third  or  fourth  body  examined.  Koeniger  reports  from  '  The 
Home  for  Invalids  and  Old  People, '  in  Hanover,  that  out  of  591  cases 
of  tuberculosis  received  there  for  treatment,  248  were  still  under  treat- 
ment, and  343  had  been  discharged.  Of  these  200  were  discharged  as 
well  or  considerably  improved,  giving  58.3  per  cent  recoveries." 

It  would  seem  fair  to  conclude  that  in  those  cases  in  which  healed 
tuberculous  lesions  were  found  without  previous  history  of  the  lesions, 
nature  was  competent  to  furnish  all  the  remedial  agencies  for  the 
cure.  Efforts  have  been  made  to  imitate  the  process  by  which  this  is 
accomplished,  and  it  is  really  approximated  in  the  modern  hygienic 
treatment  of  phthisis,  by  which  the  organism  is  placed  in  the  best 
possible  condition,  all  its  functions  being  kept  up  to  their  highest 
integrity. 

Phthisis  is  a  disease  in  which  a  serious  and  destructive  local  mani- 
festation exists,  which  is  due  to  an  infection  of  the  system  by  the  in- 


410        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

troduction  of  tubercle  bacilli.  Upon  the  recognition  of  this  simple 
pathological  fact,  the  modern  management  of  phthisis  has  become  ex- 
ceedingly simple,  and  successful.  Methodical  treatment  under  condi- 
tions which  afford  the  patient  the  best  opportunity  for  outdoor  life  in 
air  that  is  free  from  dust  and  other  vicious  elements,  the  promotion  of 
the  appetite,  the  enhancement  of  the  circulation  and  respiration,  are, 
in  brief,  the  elements  contributing  to  recovery. 

There  are  two  problems  before  the  physician  in  the  treatment  of 
this  disease,  viz.,  the  removal  of  the  infectious  element,  and  the  en- 
hancement of  resistance  to  the  latter.  Aside  from  prophylaxis,  nothing 
positive  has  been  done  toward  removing  the  agent  of  infection.  Hence 
the  most  important  indications  are  to  endow  the  system  with  the  power 
of  resisting  the  inroads  of  the  established  disease  and  to  treat  complica- 
tions and  sequelae.  These  may  be  met  by  residence  in  an  appropriate 
climate,  by  proper  and  carefully  regulated  exercise,  diet,  and  hygiene, 
by  certain  medicinal  agents,  and  last,  but  not  least,  by  a  judicious 
hydrotherapy. 

With  regard  to  exercise,  the  plan  first  adopted  by  Dettweiler  and 
Fallkenstein,  Roempler  at  Goerbersdorf ,  and  in  our  country  by  Trudeau 
and  Hance,  of  exposing  patients  to  the  constant  influence  of  pure  air  and 
sunshine,  without  incurring  liability  of  being  chilled,  is  the  most  use- 
ful, and  may  be  accomplished  in  private  practice  also,  as  I  shall  show. 

The  lungs  should  be  treated  as  is  every  other  inflamed  organ.  So 
long  as  active  inflammation  exists,  they  should  be  kept  at  rest,  or 
slowly  and  gently  expanded.  The  presence  of  fever  precludes  active 
outdoor  exercise.*  Simple  outdoor  life  must  then  be  substituted,  with 
massage  or  passive  movements  to  stimulate  the  muscular  system. 
Much  of  the  ill  effect  of  absolute  quiescence  will  be  counteracted  by 
hydrotherapy,  if  properly  applied,  and  by  exercises  which  expand  the 
lung  gently. 

Hydrotherapy  is  an  agent  whose  power  for  good  is  incalculable, 
and  which  has  given  me  more  valuable  assistance  than  all  other  means 
combined.  As  in  other  diseases,  the  judicious  application  of  cold  or 
cool  water  to  the  skin  evokes  a  stimulus  to  the  sensory  nerves,  which 

*  It  is  a  serious  error  to  depend  upon  the  mouth  temperature,  as  is  usually 
done  for  convenience  in  large  institutions,  for  a  decision  as  to  the  propriety  of 
exercise  or  rest.  The  more  nearly  normal  the  internal  temperature  is,  the  less 
reliable  is  the  mouth  temperature.  The  author  was  consulted  regarding  the 
proper  hydriatric  measures  in  a  case  of  phthisis  while  visiting  a  large  resort  for 
consumptives.  The  temperature  reported  by  the  nurse,  99.5°  P.,  not  being  in 
accord  with  the  pulse,  110  beats  per  minute,  it  was  ascertained  that  the  mouth 
had  been  used.  The  rectum  showed  one  degree  higher  (100.5°).  When  so  much 
depends  upon  the  correct  temperature,  the  rectum  would  seem  to  be  the  only 
reliable  guide. 


PHTHISIS.  411 

is  transmitted  to  the  central  nervous  system,  and  thus  invigorates  every 
function  dependent  upon  the  latter.  The  inspiration  is  gently  but 
slowly  deepened,  resulting  in  better  circulation  in  diseased  parts,  re- 
moving stagnation,  and  furthering  the  nutritive  processes  in  them. 
The  heart  is  made  to  contract  with  more  vigor  when  the  peripheral  cir- 
culation is  improved  by  the  "  shock,"  followed  by  contraction  and  dilata- 
tion of  the  cutaneous  capillaries  which  take  place.  A  superficial 
cutaneous  hyperaemia  relieves  the  congested  condition  of  the  pulmonary 
circulation.  The  appetite  is  improved ;  tissue  changes  are  increased ; 
and,  if  there  be  a  rise  of  temperature,  it  is  subdued  mildly  but  surely. 
The  alkalinity  of  the  blood  is  raised,  more  blood  cells  are  driven  into 
the  general  circulation,  and  toxins  are  eliminated,  as  has  been  shown 
by  Robin. 

The  application  of  water  in  the  treatment  of  phthisis  was  first 
recommended  by  Schedel,  who  became  interested  in  hydrothrapy  by 
observing  its  effect  in  the  hands  of  others.  Schedel  never  was  con- 
nected with  any  hydrotherapeutic  establishment.  As  a  practitioner, 
he  compared  the  hydriatic  with  the  medicinal  treatment  of  various 
diseases,  deciding  from  clinical  observation  in  favor  of  the  former, 
not  only  in  some  acute  diseases,  but  also  for  the  sequelae  of  valvular 
heart  disease  and  phthisis.  The  French  clinician  Valleix  was  "  sur- 
prised to  see  cold  water  applied  in  phthisis  without  the  bad  results 
which  he  had  anticipated, "  and  approved  of  its  use. 

Many  years  ago  Salkowsky  reported  *  106  cases  of  phthisis ;  60  in 
the  first  stage,  29  marked,  17  advanced.  After  six  months'  treatment 
by  the  cold  douche,  39  were  cured,  34  improved,  19  improving,  7  with- 
out result. 

Prof.  Ernst  Aberg,  of  Stockholm,  having  himself  been  rescued  from 
phthisis  by  ice-water  ablutions,  affusions,  and  plunges,  and  having 
treated  many  cases  of  phthisis  during  twenty-two  years'  experience, 
published  his  results  before  the  Scandinavian  Congress  of  Naturalists 
at  Stockholm  in  1880.  This  heroic  treatment  has  not  received  imita- 
tion, because  it  has  not  been  understood  that  the  application  is  very 
brief,  and  free  from  possible  harm  in  careful  hands. 

Professor  Winternitzf  refers  to  Aberg' s  ice- water  treatment  with 
favorable  comments,  stating  that,  while  he  does  not  use  such  low  tem- 
peratures as  Aberg,  he  obtains  the  stimulating  effect  by  applying  water 
of  a  somewhat  higher  temperature  under  very  considerable  pressure  by 
the  rain  bath  and  douche. 

For  many  years  the  Vienna  clinician  has  used  and  advocated 
hydrotherapy  as  an  important  element  in  the  treatment  of  phthisis, 

*  Bulletin  de  Therapie,  1877. 

f  Blatter  filr  kliuische  Hydrotherapie,  May,  1896. 


412       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

without  having  made  any  positive  impression  upon  the  medical  mind 
regarding  its  value,  outside  of  his  few  immediate  scholars  and  dis- 
ciples. 

He  published  in  1887*  the  record  of  160  cases,  with  cessation  of  the 
process  or  relative  cure  in  27  per  cent;  in  1896  he  published  299  cases, 
with  favorable  results  in  32  per  cent. 

The  systematic  application  of  douches  was  introduced  into  phthiseo- 
therapy  by  Brehmer,  of  Goerbersdorf,  the  pioneer  of  the  present  suc- 
cessful hygienic  treatment  of  phthisis.  He  says :  t  "It  remains  to  men- 
tion two  other  remedies  which  I  have  also  introduced  into  the  therapy 
of  phthisis,  and  which  have  found  rapid  dissemination,  namely,  the  wet 
rub  and  the  douche.  I  have  been  guided  by  the  fact  that  by  these 
means  the  most  extensive  organ  of  the  body,  the  skin,  may  be  brought 
into  greater  activity,  especially  to  react  promptly  to  external  irritants, 
to  increase  the  cutaneous  respiration,  and  thus  to  invigorate  the  entire 
organism. 

"  For  this  reason  I  regard  them  as  indicated  only  when  the  organism 
is  capable  of  reacting  to  the  irritant  effect  of  cold,  which  is  the  chief 
action  of  wet  rubs  and  douches.  The  patient  must  feel  pleasant  and 
comfortable  after  them,  and  the  skin  must  remain  red.  Both  of  these 
procedures  increase  the  vascular  tone,  as  is  demonstrated  by  the  sphyg- 
mograph. 

"  The  douche  is  especially  valuable  in  pleuritic  exudations,  which 
are  quickly  absorbed  under  its  action,  and  it  acts  equally  favorably 
upon  the  absorption  of  infiltrations.  But  the  douche  is  a  dangerous 
remedy ;  it  should  always  be  given  by  the  physician  and  never  by  bath 
nurses  alone,  as  is  unfortunately  the  custom  in  some  health  resorts. 
And  the  physician  even  should,  as  J.  Braun  remarks  in  his  'Balneo- 
therapy, '  understand  the  technique.  A  diploma  does  not  suffice.  The 
art  of  ordering  douches  correctly  cannot  be  taught  theoretically ;  it  can 
be  learned  only  by  demonstration  and  practice.  Moreover,  all  douches 
are  not  correctly  constructed,  which  accounts  for  the  difference  of  opin- 
ion with  regard  to  their  therapeutic  value.  For  a  good  douche  the 
water  must  be  cold  and  be  delivered  with  considerable  force,  so  that 
the  stream  should  have  a  homogeneous  diameter.  It  must  not  be  a 
mere  sprinkling,  but  a  strong  douche.  In  most  douche  apparatuses 
the  conducting  pipes  make  so  many  windings  that  the  active  force  of 
the  water  is  almost  neutralized  before  it  falls  upon  the  patient.  The 
size  of  openings  in  the  douche  is  also  not  a  matter  of  indifference." 

This  quotation  shows  plainly  that  Brehmer  correctly  valued  the 

*"Klinische  Studien,"  1887. 

f  "  Die  Therapie  der  chronischen  Lungenschwindsucht, "  p.  327. 


PHTHISIS.  413 

douche  if  properly  administered,  an  observation  which  I  can  confirm, 
especially  with  regard  to  the  technique,  pressure,  and  temperature. 

The  enhancement  of  nutrition  being  the  chief  aim  in  phthisis,  hydro- 
therapy  offers  a  powerful  therapeutic  agent,  which,  rightly  used,  must 
be  of  immense  value. 

Aside  from  this  important  consideration,  the  predisposition  to 
repeated  colds  and  consequent  probable  aggravation  of  the  local  proc- 
esses and  general  symptoms  may  be  diminished  by  the  neuro-vascular 
discipline  to  which  the  skin  is  daily  subjected  by  appropriate  water 
treatment.  This  hardening  process  has  long  been  recommended  for 
those  predisposed  to  phthisis.  Ziemssen  speaks  of  it  in  his  lectures  on 
the  treatment  of  tuberculosis  as  "  a  remedy  of  extraordinary  value  for 
persons  who  are  predisposed  to  or  have  acquired  phthisis." 

The  technique  and  procedures  applicable  in  this  disease  must  neces- 
sarily vary  with  each  case.  Brief  applications  of  low  temperature,  as 
by  douche  or  rain  bath,  or  rapid  ablutions,  are  followed  by  rapid  reac- 
tion, and,  if  well  borne,  are  exceedingly  useful  as  tonics ;  while,  on 
the  contrary,  in  cases  suffering  from  elevated  temperatures  and  great 
debility,  more  gentle  procedures,  as  the  sheet  bath,  full  bath,  wet 
packs  with  perhaps  higher  temperatures  of  the  water,  are  required.  I 
have  seen  febrile  cases  seriously  injured  by  too  cold  procedures,  the  latter 
being  indicated  in  a  febrile  or  mildly  febrile  conditions.  This  is  contrary 
to  views  usually  entertained  on  the  therapeutic  action  of  cold  baths, 
which  are  regarded  as  heat-reducing  in  proportion  to  the  lowering  of 
their  temperatures.  My  observations  at  the  Montefiore  Home  for 
Chronic  Invalids,  in  which  cases  of  the  most  forlorn  type,  so  far  as 
previous  hygienic  surroundings  are  concerned,  are  received,  have  led  me 
to  adopt  the  following  course,  because  the  skins  of  many  of  these  poor 
people  have  long  been  strangers  to  cold  water,  or,  indeed,  water  of  any 
kind.  After  a  thorough  cleansing  with  a  warm  bath  or  soap  ablution, 
a  day  is  allowed  to  elapse.  The  patient  is  now  wrapped  snugly, 
quite  naked,  in  a  woollen  blanket,  so  that  his  body  is  excluded  from 
air;  other  blankets  are  piled  over  him.  The  windows  are  opened  and 
he  is  given  a  small  glass  of  iced  water  every  ten  minutes.  Having  lain 
in  this  position  an  hour,  a  part  of  the  body  is  exposed  and  bathed  as 
follows :  With  a  towel  the  face  is  well  bathed  in  water  at  50°.  A  basin 
of  water  at  75°  is  made  ready,  into  which  the  attendant  dips  his  right 
hand,  covered  by  a  mitten  or  glove  of  Turkish  towelling.  The  back  of 
the  trunk  and  thighs  having  been  exposed,  it  is  rapidly  washed  and 
rubbed  with  the  wet  glove  dipped  in  water  at  75°,  then  dried.  The 
anterior  portion  of  the  trunk  is  similarly  treated.  At  the  termina- 
tion of  this  ablution  the  patient  is  rapidly  rubbed  all  over  with  a 


414       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

coarse  towel.  This  treatment  is  repeated  daily,  the  temperature  of 
the  water  being  reduced  two  degrees  on  each  occasion,  until  60"  is 
reached. 

From  the  Berlin  University  hydrotherapeutic  clinic  of  Professor 
Brieger,  Meffiat  *  contributes  a  treatment  adapted  to  home  use,  very 
similar  to  the  above.  He  advises  thorough  warming  in  bed  or  in  the 
dry  pack,  followed  by  rapid  ablution  and  sprinkling  from  a  watering 
pot  of  water  not  exceeding  77°  F.,  and  the  return  of  the  patient  to 
the  warm  bed  or  dry  pack  in  order  to  hasten  reaction.  While  I  think 
that  the  latter  may  be  useful  in  the  beginning  of  this  neurovascular 
training,  exercise  in  the  open  air  will  be  far  more  effective,  because  it 
enhances  all  the  processes  which  the  hydriatric  procedure  has  started — 
deepened  inspiration,  better  pulse  tension,  increased  blood  [pressure, 
and  consequent  improvement  of  appetite  and  nutrition.  Care  must  be 
exercised  in  making  this  sprinkling  very  rapidly  and  to  provide  a  tub 
of  water  at  105°  F.  for  the  feet  during  the  process. 

The  patient's  reactive  capacity  having  been  carefully  raised  by  this 
treatment,  more  active  measures  may  be  applied.  The  cold  rub  and 
drip  sheet  described  elsewhere  are  now  indicated.  It  should  be  care- 
fully administered  by  a  well -trained  attendant;  the  technique  de- 
scribed must  be  strictly  followed  and  the  patient  carefully  observed, 
for  its  success  or  failure  depends  upon  ascertaining  daily  the  reactive 
capacity  of  the  patient,  and  increasing  or  diminishing  the  tempera- 
ture, duration,  and  mechanical  impact,  according  to  the  effect  pro- 
duced. The  "  cold  rub  "  offers  an  excellent  procedure  for  preparing 
the  skin  for  the  more  intense  "  drip  sheet "  which  abstracts  more  heat 
and  arouses  the  entire  organism  just  as  outdoor  exercise  does,  without, 
however,  elevating  the  temperature.  The  experienced  clinician  must 
recognize  the  great  advantage  of  this  therapeutic  combination  when 
temperature  rise  forbids  exercise.  These  are  the  most  effective  pro- 
cedures for  home  treatment. 

The  most  useful  hydriatric  procedure  in  phthisis,  however,  is  the 
circular  douche  (needle  bath).  Unfortunately,  this  can  be  obtained 
only  in  institutions.  The  water  should  have  considerable  force  in 
order  to  fulfil  the  demand  of  Brehmer,  which  every  experienced  hydro- 
therapist  will  approve,  that  considerable  force  is  a  sine  qua  non  to  pre- 
vent chilling  and  too  great  abstraction  of  temperature.  The  patient 
should  receive  this  douche  at  90°,  gradually  reduced  in  the  course 
of  one  minute  to  85°.  The  latter  temperature  maybe  decreased.  The 
duration  should  not  exceed  one  minute  in  the  average  case,  but  it  may 
be  modified  to  suit  the  indication  of  each  case.  The  advantage  of  this 
douche  over  other  baths  lies  in  the  pressure  with  which  the  water 
*  Deutsche  medicinische  Wochenschrift,  May  9th,  1901. 


PHTHISIS.  415 

strikes  the  body,  affording  a  kind  of  massage,  which  assists  in  pro- 
ducing reaction  even  in  feeble  individuals.  But  it  should  not  be  ap- 
plied without  previous  training  of  the  skin,  as  above  described.  The 
circular  douche  is  an  antipyretic  of  great  value,  if  its  temperature  is 
not  below  85°. 

To  enhance  the  tonic  effect  I  have  added  the  fan  douche,  which 
succeeds  the  circular  douche  for  a  very  brief  time.  It  is  my  custom 
to  order  this  douche  under  a  pressure  of  thirty  pounds  at  80°  for  ten 
seconds,  moving  it  slowly  up  and  down  the  back,  to  avoid  the  current 
of  cold  air  which  the  rapid  agitation  of  this  fan-shaped  stream  always 
produces.  This  douche  may  be  reduced  daily  one  degree,  until  70° 
is  reached.  It  is  confined  to  the  back  only.  If  the  patient's  reaction 
is  good  under  this  treatment,  the  general  fan  douche,  i.e.,  playing  it 
over  the  anterior,  posterior,  and  lateral  portions  of  the  body,  may  be 
substituted  for  the  circular  douche  at  a  temperature  of  80°,  daily 
reduced  one  degree,  until  65°  is  reached.  Good  reaction  must  always 
be  provided  for.  The  skin  must  not  become  pale  under  it,  and  the 
patient  must  not  be  chilled  by  it;  at  least,  any  coldness  he  may  expe- 
rience should  disappear  after  he  is  dried.  This,  indeed,  is  a  test  of 
the  efficiency  of  all  hydriatric  procedures.  Decided  chilliness,  con- 
tinuing after  thorough  drying  and  friction,  is  an  evidence  of  improper 
selection  of  the  procedure — its  temperature,  duration,  or  mechanical 
impact.  These  should  be  modified  as  indicated  by  the  effect  observed 
each  day  and  reported  to  the  medical  attendant,  just  as  the  effect  of  a 
Brand  bath  or  of  a  dose  of  medicine  is  reported  by  the  nurse  and  acted 
upon  by  the  physician. 

For  the  purpose  of  enhancing  the  reactive  capacity  of  phthisical 
patients,  the  hot-air-cabinet  bath  offers  an  excellent  substitute  for  the 
more  tedious  dry  pack  above  described.  It  dilates  the  cutaneous  ves- 
sels and  renders  the  effect  of  the  hydriatric  procedure  more  pronounced. 
Care  should  be  taken,  however,  that  the  patient  be  not  permitted  to 
perspire  in  the  hot-air  bath.  This  error  may  prove  serious  by  destroy- 
ing the  patient's  reaction  and  reducing  his  weight  and  strength. 

As  a  palliative  for  the  cough  and  for  the  reduction  of  febrile  move- 
ment, the  chest  compress  is  a  valuable  measure.  It  should  be  applied 
chiefly  at  night,  or  when  the  patient  is  resting,  the  chest  being  thor- 
oughly rubbed  with  water  at  60°  each  time  it  is  renewed. 

This  treatment,  viz.,  hot-air  baths  short  of  perspiration,  followed 
by  the  circular  bath  and  fan  douche,  gradually  lowered  and  daily 
adapted  to  the  patient's  condition,  especial  regard  being  given  to  febrile 
conditions  (when  the  milder  antipyretic  procedures  come  into  play), 
may  be  continued  for  several  months.  The  frequency  of  treatment  may 
be  reduced  to  three  or  even  two  a  week.  Now  the  patient  may  become 


416       THE  PKINOIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

accustomed  to  taking  a  morning  plunge  into  a  tub  containing  water  at 
80°;  the  bath  temperature  may  be  reduced  daily  two  or  more  degrees 
until  it  reaches  60°.  This  must  be  a  brief  dip;  preceded  by  saturating 
the  head  with  water,  a  rapid  emergence  from  the  tub  must  be  insisted 
upon,  followed  by  thorough  drying  and  good  friction.  A  brisk  walk  into 
the  morning  air  may  follow,  then  a  light  breakfast,  which  the  patient 
will  eat  with  relish  after  such  a  dip.  This  daily  training  of  the  cutane- 
ous nerves  and  vessels,  with  the  consequent  refreshment  of  body  and 
mind,  may  contribute  more  to  the  recovery  of  the  patient  than  any 
other  single  remedy.  The  result  is  usually  an  improved  appetite,  bet- 
ter digestion  and  assimilation,  improved  hsematosis,  deepened  inspira- 
tion, vigorous  circulation ;  in  brief,  an  enchantment  of  all  those  func- 
tions which  contribute  to  the  maintenance  of  health,  and  on  whose 
integrity  depends  the  prolongation  of  life.  No  specific  effect  is  aimed 
at;  none  is  obtained.  The  patient  is  treated — not  the  disease.  He 
is  removed  from  unfavorable  environment,  out  of  reach  of  disease  pro- 
ducing and  maintaining  elements;  his  organism  is  invigorated  and 
steeled  against  the  enemy  which  is  "gnawing  at  his  vitals."  The 
prime  essentials  for  this  purpose  are  a  good  appetite  and  digestion. 
And  these  are  the  chief  and  most  palpable  effects  of  a  judicious  hydro- 
therapy  in  phthisis.  Even  in  the  most  desperate  conditions  these 
may  be  observed  sometimes.  A  young  man  from  Charlotte,  N.  C., 
gained  fifteen  pounds  in  two  months,  despite  the  advance  of  his  malady 
to  the  third  stage.  While  evening  exacerbation  with  high  temperature 
and  profuse  sweats  undermined  his  strength,  his  appetite  was  main- 
tained, and  he  consumed  during  the  first  half  of  the  day  a  sufficient 
quantity  of  food,  of  which  cream  cheese  was  a  large  proportion,  to  leave 
for  Colorado  with  an  increase  of  weight. 

Professor  Winternitz  states  that  among  twenty -four  hundred  patients 
treated  at  his  institution  in  Kaltenleutgeben  for  various  diseases,  fifty- 
six  per  cent  showed  an  increase  of  weight.  A  similar  result  has  been 
observed  during  the  past  seven  years  in  the  Hydriatric  Institute,  when 
the  cases  treated  for  obesity  or  other  diseases  demanding  increased  tis- 
sue change  are  eliminated. 

From  the  large  clinical  material  at  my  disposal  in  hospital  and 
private  practice,  the  following  brief  histories  are  selected  not  so  much 
to  demonstrate  the  value  of  hydrotherapy  in  phthisis  as  to  elucidate 
the  procedures  adopted: 

Mr.  S ,  from  Owensboro,  Ky. ,  aged  26  years,  merchant,  consulted  me  at 

Long  Branch  on  July  29th,  1892.  Looks  pale,  emaciated  ;  states  that  he  has  been 
losing  flesh  and  coughing  seven  months ;  is  constipated,  has  no  appetite.  Caught 
cold  during  a  fire.  No  hereditary  predisposition.  Temperature,  101° ;  pulse, 
120.  Physical  signs :  Percussion  over  left  supraclavicular  space  dull,  respira- 


PHTHISIS.  417 

tory  murmur  in  left  apex  harsh,  expiration  prolonged.  Ordered  calomel,  six 
grains,  and  absolute  rest. 

July  31st.  Feels  better.  Temperature,  99°  F.  Ordered  to  Hydriatric  Insti- 
tute for  treatment.  Here  he  weighed  (nude)  one  hundred  and  six  and  one-half 
pounds.  He  received  a  hot-air  bath  until  warm,  to  enhance  his  reactive  powers. 
This  was  followed  by  a  circular  douche  of  95°  F. ,  reduced  gradually  to  80",  for 
forty  seconds  under  ten  pounds'  pressure,  gradually  increased  ;  then  a  fan  douche 
ut  fifteen  pounds'  pressure,  gradually  increased  to  thirty  pounds  for  four  seconds 
at  70°. 

This  procedure  was  repeated  daily.  He  reported  again  at  Long  Branch  ten 
days  later,  looking  better,  appetite  improved,  and  with  a  gain  of  one  and  one- 
half  pounds.  A  friend  having  advised  him  to  have  his  sputum  examined,  the 
latter  was  found  to  contain  bacilli.  He  was  urged  by  another  friend  to  see  an 
eminent  consultant,  who,  after  careful  examination,  pronounced  him  phthisical, 
advised  him  to  leave  at  once  for  Asheville,  N.  C.,  and  ordered  him  to  take 
creosote.  As  he  was  improving  under  hydrotherapy,  I  regarded  his  departure 
with  disfavor  and  advised  continuance  of  treatment  by  water. 

September  8th.  The  hot-air  bath,  followed  by  circular  douche,  80°  to  70°, 
and  fan  douche,  70°  to  45°,  has  been  continued,  until  to-day  the  patient  weighs 
one  hundred  and  fourteen  pounds,  a  gain  of  seven  and  one-half  pounds  in  five 
weeks.  Appetite  is  excellent;  cough  still  troublesome  ;  is  very  hoarse.  Tem- 
perature, 101°.  Benzoin  inhalation  and  one-fourth  grain  codeine  every  four  hours 
improved  cough  in  two  days,  during  which  time  hydriatic  treatment  had  been 
discontinued.  It  was  now  resumed. 

September  12th.  Temperature  is  99° ;  cough  reduced  to  a  minimum  ;  appe- 
tite excellent.  Weight,  one  hundred  and  thirteen  and  one-half  pounds.  Has 
been  taking  six  drops  creosote,  t.i.d.  ;  as  it  nauseates  him  it  is  discontinued. 
Ordered  maltine  with  peptones,  t.i.d.,  in  milk. 

September  19th.  Hot-air  bath  (170°)  three  minutes.  Circular  douche,  80° 
reduced  to  64°,  one  minute,  from  which  he  reacted  well.  Cough  troublesome. 
A  spirometer  test  shows  190°  before  and  260°  after  treatment,  which  is  20°  above 
the  average  for  his  height. 

September  20th.     Dr.  J.  S.  Ely  reports  tubercle  bacilli  in  small  numbers. 

December  30th.  With  occasional  interruptions  and  loss  of  weight,  patient 
has  progressed  well,  and  to-day  weighs  one  hundred  and  twenty-one  and  a  half 
pounds,  looks  well,  coughs  but  little,  has  no  pyrexia,  and  is  anxious  to  go  home. 

Dr.  Freudenthal,  who  treated  his  throat,  wrote  under  date  of  January  12th, 
1893,  after  detailing  from  his  case  records  the  physical  signs  he  had  found  on  July 
27th,  and  again  on  November  llth,  1892  :  "Patient  looks  and  feels  much  better, 
and  has  gained  ten  pounds  in  weight.  Ulcerations  of  the  ligamentum  glosso-epi- 
glotticum  and  of  the  vocal  cords  have  healed  under  lactic  acid  and  menthol  oil 
(twenty  per  cent).  Although  I  am  not  so  optimistic  as  you  are  regarding  water 
treatment,  I  must  acknowledge  that  the  improvement  in  the  case  is  remarkable. " 

January  21st.  Patient  is  now  almost  free  from  cough  and  has  good  appetite. 
Weighs  one  hundred  and  twenty-two  and  a  half  pounds,  a  gain  of  sixteen  pounds, 
and  five  pounds  more  than  he  ever  weighed  in  health.  Dr.  Van  Gieson  reports 
that  no  tubercle  bacilli  could  be  found  after  examining  several  slides. 

This  patient  remained  well  for  six  years,  but  has  recently  returned 
for  treatment  on  account  of  throat  trouble. 

No  change  has  been  made  in  his  diet  and  mode  of  life.     This  case 

27 


418       THE  PRINCIPLES  AND  PRACTICE  OF  HYDROTHERAPY. 

is  a  clear  illustration  of  the  utility  of  a  judicious  hydrotherapy  in 
improving  nutrition  in  cases  that  usually  thwart  us. 

A  few  brief  histories  from  the  hospital  records  *  (Montefiore  Home) 
may  "  point  a  lesson. "  The  preparatory  hydriatric  measures  adopted 
in  these  cases  are  omitted  for  the  sake  of  brevity.  The  rain  bath 
referred  to  in  these  histories  is  the  circular  douche. 

J.  D ,  aged  36 ;  ill  two  years  and  a  half.     Had  hemorrhage  two  years  ago, 

since  then  night  sweats,  cough,  expectoration,  and  pain  in  left  side.  Has  been 
treated  twice  at  Mount  Sinai  Hospital  for  phthisis. 

Physical  signs  on  admission  :  Dulness  over  left  apex,  impaired  breathing ; 
pleuritic  friction  rales  on  right  side  along  axillary  space.  Weight,  one  hundred 
and  sixty-two  and  one-half  pounds. 

Treatment :  General  sustaining  measures,  with  daily  rain  bath  at  65°  for 
thirty  seconds ;  damp  compresses  to  chest. 

Result :  Improvement  of  all  symptoms,  and  gain  of  fourteen  pounds  and  a 
half  during  ten  weeks. 

December  16th,  1890.  He  was  subjected  to  tuberculin  treatment  until  April 
29th,  other  treatment  being  suspended. 

The  patient  lost  so  much  in  weight  and  general  appearance  that  I  fre- 
quently felt  misgivings  as  to  the  propriety  of  subjecting  him  to  the  experiment. 
The  rain  baths  were  resumed,  and  his  general  condition  at  once  improved  and 
appetite  returned. 

At  the  present  time  there  are  no  cough,  the  least  amount  of  expectoration,  and 
but  few  pleuritic  friction  sounds  over  left  apex.  His  weight  is  one  hundred  and 
seventy-eight  pounds  and  a  half.  Dr.  Hodenpyl  reported  :  First  examination, 
about  ten  bacilli  to  the  field  ;  second  examination,  very  few  bacilli ;  third,  fourth, 
and  fifth  examinations,  no  bacilli. 

This  patient  may  be  regarded  as  recovered,  judging  from  physical  signs,  sub- 
jective symptoms,  his  general  condition,  and  the  absence  of  bacilli. 

J.  J ,  aged  33,  admitted  February  3d,  1890.     Family  history  negative. 

Illness  of  one  and  one-half  years'  duration.  Began  with  pulmonary  hemorrhage, 
followed  by  cough  ;  spat  blood  two  days,  and  felt  better  after  it.  Continued  to 
cough  until  December,  1889,  when  he  had  a  most  severe  hemorrhage,  became  very 
weak,  and  was  confined  to  bed. 

Continues  weak ;  cannot  work ;  coughs  a  great  deal ;  expectorates  a  little 
mucus,  often  mixed  with  blood.  Complains  of  pains  in  back,  tickling  in  larynx  ; 
appetite  is  good,  bowels  are  regular. 

Physical  signs :  Dulness  over  right  upper  lobe,  as  far  as  first  rib,  posteriorly 
to  border  of  scapula  ;  slight  dulness  over  left  apex  ;  uncertain  and  accentuated 
breathing,  with  prolonged  expiration  over  right  apex,  feeble  respiration  over 
left.  Temperature  normal ;  pulse,  84 ;  respiration,  28. 

February  18th.  Weight,  one  hundred  and  thirty -five  pounds.  Treatment, 
one-minim  creosote  pill,  two  t.i.d. ,  with  cod -liver  oil,  3  ss.  Circular  bath  at 
65°  for  thirty  seconds  daily. 

March  1st.  Coughs  only  a  little  in  the  morning.  Weight,  one  hundred  and 
forty -two  and  a  half. 

March  20th.  In  fair  condition  ;  quite  a  little  cough  in  the  morning.  Weight, 
one  hundred  and  forty -nine  and  a  half. 

April  25th.     Weight,  one  hundred  and  sixty-one  and  a  half. 

*  Transactions  Medical  Society  of  New  York. 


PHTHISIS.    .  419 

May  5th.  Appetite  not  so  good  lately ;  otherwise  feels  very  comfortable. 
Coughs  sometimes  in  the  morning ;  no  expectoration.  Weight,  one  hundred  and 
sixty  and  a  half. 

Dr.  Dessau  examined  the  patient.  He  found  very  slight  broncho-vesicular 
respiration  in  the  left  apex.  Impaired  resonance  on  percussion  of  the  same,  and 
very  few  mucous  rales.  On  the  left  below  the  scapula  very  few  subcrepitant 
rfiles,  probably  due  to  old  pleuritic  adhesions. 

May  llth.  Eight  apex,  vesicular  respiration,  and  very  slightly  impaired  reso- 
nance, which  is  often  found  normally  in  the  right  chest ;  so  practically  we  can 
find  now  only  a  very  slight  infiltration  of  left  apex,  with  some  old  pleuritic 
adhesions.  Weight,  one  hundred  and  sixty-one,  a  gain  of  twenty-six  pounds. 
Discharged  at  his  own  request,  as  he  desired  to  go  to  work. 

H.  S ,  aged  31  years,  admitted  May  3d,  1890.  Family  history  negative ; 

always  well  until  May,  1880,  when  he  had  first  pulmonary  hemorrhage ;  was 
confined  to  bed  eight  weeks  with  cough,  night  sweats,  and  afternoon  fevers.  In 
September,  1889,  and  January,  1890,  he  had  hemorrhages,  and  went  to  Mount 
Sinai  Hospital,  whence  he  was  discharged  improved  in  seven  weeks.  He  had 
cough,  expectoration,  and  pain  in  the  chest ;  no  appetite  when  admitted. 

Physical  examination  :  Dulness  over  right  third  anteriorly  and  posteriorly ; 
subcrepitant  and  friction  rales ;  broncho-vesicular  respiration,  with  prolonged 
expiration.  On  left  side,  prolonged  expiration,  with  some  friction  sounds  over 
left  apex.  Weight,  one  hundred  and  twenty -nine  and  three-quarters  pounds. 

August,  1890.     Sputum  found  to  contain  bacilli. 

In  September,  1880,  he  had  a  hemorrhage.  During  this  time  he  received  rain 
baths,  syrup  of  hypophosphites,  and  creosote  ;  at  times  cod-liver  oil.  Under  this 
treatment  he  steadily  improved,  so  that  when  he  was  subjected  to  tuberculin  in- 
jections, on  December  6th,  1890,  he  weighed  one  hundred  and  forty-six  pounds— a 
gain  of  sixteen  and  one-quarter  pounds  in  six  months  and  a  half — and  no  bacilli 
were  found  by  Dr.  Hodenpyl  in  his  sputum. 

There  were  still,  however,  dulness  over  right  apex,  broncho-vesicular  respira- 
tion, and  subcrepitant  rSles.  His  temperature  was  99°.  April  15th,  tuberculin 
injections  discontinued. 

There  being  no  tubercle  bacilli  in  the  sputum  and  no  cough  or  expectora- 
tion, and  the  physical  signs  being  only  a  slight,  jerky  respiration,  he  was  dis- 
charged as  cured,  April  29th,  weighing  one  hundred  and  forty -nine.  He  had  in- 
creased twenty  pounds  since  his  admission,  and  three  and  one-half  pounds  since 
injections  were  begun,  during  the  continuance  of  which  he  lost  very  considerably. 
He  went  to  work  at  Bronxville,  N.  Y. 

A.  V ,  a  nurse  in  the  Montefiore  Home,  weighed,  in  the  summer  of  1890, 

one  hundred  and  thirty-eight  pounds.  She  was  constantly  engaged  in  the  wards, 
in  which  her  mother  was  also  a  nurse.  She  began  to  lose  flesh  while  at 
work ;  cough  and  expectoration  were  pronounced,  and  she  had  two  small 
hemorrhages. 

Physical  examination  revealed  impaired  resonance  over  left  apex,  jerky, 
exaggerated  respiration ;  fine,  moist,  and  pleuritic  rUles.  Bacilli  abundant  in 
the  sputum.  Weight,  one  hundred  and  twenty-six  pounds  on  January  5th,  when 
she  was  subjected  to  tuberculin  injections. 

She  received  twenty-one  injections,  progressively  increased.  They  were 
always  followed  by  decided  febrile  reaction.  The  last  injection  of  45  mgra.  was 
administered  on  the  first  of  April,  and  was  followed  by  very  slight  reaction. 
During  the  entire  treatment  she  had  daily  rain  baths. 


420       THE   PRINCIPLES   AND   PRACTICE   OF  HYDROTHERAPY. 

April  10th.  Cough,  expectoration,  night  sweats,  and  physical  signs  had 
ceased  ;  her  weight  had  increased  to  one  hundred  and  thirty-two  pounds,  and,  no 
bacilli  being  found  in  the  sputum,  she  was  discharged  at  her  own  request  as 
cured.  Last  year  (1896)  she  was  still  working  as  a  private  nurse,  feeling  per- 
fectly well. 

In  these  cases  the  effect  of  tuberculin  was  either  deleterious  or  neg- 
ative, while  that  of  the  rain  bath  was  excellent. 

B.  8 ,  aged  18  years,  architect,  admitted  November  19th,  1890.  Mother 

died  of  chronic  phthisis.  Has  been  ill  since  he  had  an  attack  of  pneumonia  two 
years  ago,  with  night  sweats,  troublesome  cough,  and  loss  of  flesh. 

Physical  signs :  Those  of  a  cavity.  Tympanitic  dulness  over  the  upper  third 
of  left  lung  anteriorly,  cracked-pot  sound,  cavernous  rales,  tuberculous  breathing, 
signs  of  catarrh  in  right  apex.  Complains  of  palpitation  greatly.  Weight,  out 
hundred  and  fiften  pounds.  Bacilli  numerous. 

Treatment.    Rain  baths,  70°  to  65°,  thirty  seconds ;  cod-liver  oil  and  creosote. 

December  16th.  Up  to  that  time  his  weight  had  increased  eight  pounds,  al- 
though the  physical  signs  were  the  same  as  on  admission.  Temperature  normal. 
He  was  now  subjected  to  tuberculin  treatment,  under  which  he  increased  (as  an 
exception  to  the  rule) ,  on  April  10th,  to  one  hundred  and  thirty-eight  pounds. 
Cough  did  not  trouble  him  now,  and  he  expectorated  very  little.  A  few  bacilli 
at  every  examination.  Physical  signs  not  so  pronounced.  Rales  few,  and  there 
was  evidence  of  contraction  of  cavity.  The  palpitations,  which  troubled  him 
greatly,  had  disappeared. 

Dr.  Hodenpyl's  report  is  interesting  : 

December  16th.     One  hundred  tubercle  bacilli  to  each  cover  glass. 

March  1st.     Two  bacilli  to  field. 

May  7th.  His  weight  is  one  hundred  and  thirty -nine  pounds.  He  has  been 
receiving  rain  baths  since  the  injections  were  stopped.  He  looks  well,  and  may 
be  regarded  as  markedly  improved. 

He  was  discharged  on  July  14th,  weighing  one  hundred  and  forty  pounds,  and 
looking  the  picture  of  health.  He  settled  in  Denver,  Col. ,  and  when  last  heard 
from  was  following  his  vocation  as  an  architect. 

This  case  offers  another  illustration  of  the  influence  of  hydrotherapy 
on  the  nutrition. 

Dr.  Bloch's  Montefiore  Home  report  for  1892  says: 

"  This  remarkable  success  is  chiefly  due  to  the  water  treatment,  the  most  char- 
acteristic feature  of  our  institution.  S.  K ,  after  having  gone  to  Europe  for 

his  health  for  one  year,  came  to  the  Home  with  a  cavity  in  his  left  apex  and  con- 
siderable organic  change  in  the  lung.  After  one  year's  treatment  he  was  dis- 
charged well ;  not  only  fever,  night  sweats,  cough,  pain,  but  even  the  objective 
signs  of  the  cavity  having  disappeared,  and  with  a  gain  of  twelve  pounds.  He 
has  been  working  hard  as  a  painter  for  the  last  six  months,  and  feels  well.  " 

In  the  report  for  1893,  of  Drs.  Bloch  and  Frankel,  house  physi- 
cians of  the  Montefiore  Home,  the  following  sentence  occurs : 

"  Too  much  praise  cannot  be  given  to  our  hydrotherapeutic  arrangements, 
which  constitute  a  most  powerful  element  in  our  therapeutics.  We  have  suc- 
ceeded in  curing  thirty -one  patients  last  year,  all  of  whom  have  been  discharged. 


PHTHISIS.  421 

Twenty-nine  more  have  been  discharged  improved.  Among  those  cured  or 
essentially  improved,  there  have  been  six  consumptives,  some  of  whom  had 
come  to  the  home  with  cavities. " 

A  case  from  the  report  for  1894,  by  Drs.  Bloch  and  Frankel,  is 
briefly  told : 

E.  F ,  33  years  old,  came  to  the  Home  in  November,  1892,  after  a  large  hem- 
orrhage, with  the  physical  signs  of  a  small  cavity  in  left  apex  and  infiltration  of 
right  apex.  He  was  discharged  June,  1894,  "  cured, "  having  felt  perfectly  well 
for  a  whole  year ;  expectoration,  bacilli,  and  physical  signs,  after  contraction  of 
cavity,  having  disappeared,  and  with  a  gain  of  twenty -seven  pounds. 

The  Montefioro  Home  was  the  pioneer  of  systematic1;  hydrotherapy , 
and  its  only  exponent  for  many  years  in  this  country  and  in  all  other 
English-speaking  countries. 

The  records  of  this  institution,  which  contain  a  large  number  of 
phthisical  cases,  present  abundant  evidence  in  detail  of  the  influence 
of  systematic  hydrotherapy,  chiefly  circular  douches.  The  brief  out- 
line histories  furnished  above,  suffice  as  examples. 

In  view  of  the  results  obtained  in  this  large  institution  from  the 
judicious  and  systematic  application  of  douches,  it  is  remarkable  that 
the  average  medical  practitioner  in  this  country  is  still  so  unacquainted 
with  it  that  he  shrinks  with  horror  at  the  very  mention  of  applying 
"  cold  water"  to  the  skin  of  a  consumptive.  The  proof  of  its  value  is 
so  abundant  that  "  he  who  runs  may  read." 

A  sufficient  number  of  clinical  histories  has  been  cited  from  pri- 
vate and  hospital  records  to  demonstrate  the  hydriatric  methods  pur- 
sued. A  larger  number  of  histories  would  burden  the  reader  without 
convincing  him  more  fully  that  hydrotherapy  furnishes  a  precious 
auxiliary  in  the  hygienic  management  of  phthisical  patients.  The  lat- 
ter are  too  often  condemned  to  exile  from  home  and  friends,  when  the 
employment  of  hydrotherapy  would  invest  the  case  with  a  favorable 
aspect  that  would  encourage  patient  and  physician  alike,  and  enable 
the  former  to  remain  among  his  dear  ones. 

In  an  exhaustive  essay  on  the  hydriatic  treatment  of  tuberculosis 
Dr.  J.  H.  Kellogg  *  writes  that  "  scores  of  persons  are  to-day  leading 
useful  lives  as  the  result  of  the  employment  of  these  rational  measures 
who  would  have  unquestionably  been  buried  long  ago  without  this 
treatment.  It  is  my  firm  belief  that  the  general  adoption  of  hydriatic 
measures  in  the  treatment  of  pulmonary  tuberculosis  by  the  profession 
at  large,  and  especially  their  application  in  the  incipient  stages,  would 
result  in  saving  nine-tenths  of  the  sufferers  from  this  disease." 

*  Medical  News,  November  10th,  1900. 


422       THE   PRINCIPLES  AND   PRACTICE  OF   HYDROTHERAPY. 

A  CONTROL  EXPERIMENT  IN  HYDROTHERAPY  OF  PHTHISIS 

It  is  a  sad  commentary  OP  the  otherwise  excellently  managed  sana- 
toria for  phthisis  in  this  country  that  hydrotherapy  has  not  become  a 
regular  part  of  management.  Despite  the  fact  that  one  of  the  most 
eminent  phthisiotherapists  in  America  has  stated,  after  studying  the 
most  progressive  methods  of  European  institutions,  that,  "  next  to  aero- 
therapy,  hydrotherapy  is  the  most  important "  (Knopf),  there  are  few 
sanatoria  in  which  water  is  systematically  applied.  Indeed,  in  prom- 
inent institutions  in  which  an  expensive  apparatus  for  douching  has 
been  installed  and  in  which  I  gave  the  nurses  and  physicians  a  prac- 
tical demonstration  of  the  most  appropriate  procedures,  hydrotherapy 
is  rarely  if  ever  brought  into  requisition,  if  I  may  credit  the  reports 
of  patients  who  resided  there  for  prolonged  periods.  In  view  of  this 
unfortunate  fact  it  may  not  be  unprofitable  to  cite  at  length  the  com- 
parative studies  of  Kuthy  *  of  one  thousand  cases  of  tuberculosis. 
"  Four  years  ago,"  writes  Kuth}',  "  I  stated  that  the  sanatoria  for 
tuberculosis  will  never  do  justice  to  their  difficult  demands  until  they 
possess  a  well-arranged  water  institute,  conducted  by  properly  in- 
structed attendants."  Kuthy  never  pronounces  a  case  cured  until  two 
years  have  elapsed  without  all  manifestations.  He  does  not  hunt  for 
statistical  laurels  and  judges  cases  and  results  with  the  utmost  rigor, 
approaching  pessimism.  In  this  essay  Kuthy  compares  the  results  of 
statistics  of  his  own  institution  in  Budapest  with  those  of  one  of  the 
best  conducted  sanatoria  in  Germany — Belzig  near  Berlin.  Among  the 
cases  in  the  first  stage  of  phthisis  which  were  treated  with  tuberculin 
and  the  most  approved  dietetic  and  hygienic  methods  39  per  cent  were 
discharged  cured  in  1905;  while  from  the  Budapest  sanatorium  there 
were  discharged  as  cured  53.9  per  cent  as  clinically  cured  in  1903. 
The  only  cardinal  difference  in  the  management  of  cases  in  these  two 
large  sanatoria  is  that  in  Belzig  the  only  form  of  hydrotherapy  con- 
sists, as  in  most  German  institutions,  of  douches  which  can  be  borne 
only  by  a  fraction  of  patients,  while  in  the  Elizabeth  sanatorium  at 
Budapest  all  hydriatric  procedures  are  utilized  with  careful  individ- 
ualization,  and  that  thus  the  latter  is  richer  in  a  powerful  therapeutic 
method  than  the  most  exemplary  conducted  Berlin  institute. 

The  author  feels  justified  in  reproducing  briefly  the  following  ex- 
cellent practical  suggestions  of  Kuthy  because  they  are  in  accordance 
with  the  rationale  of  hydrotherapy  and  his  own  observations,  and 
they  are  the  result  of  observations  of  an  enormous  clinical  material. 
How  insignificant  the  observation  of  a  few  cases  or  of  several  hundred 
cases  is  in  actual  therapeutic  deduction,  only  the  fair-minded  clini- 
*  Blatter  f  iir  klinische  Hydrotherapie,  May,  1904. 


PHTHISIS.  423 

cian  who  is  willing  to  submit  to  the  decision  of  the  bedside  may  ap- 
preciate. In  Kuthy's  institution  the  morning  bath  is  most  frequently 
resorted  to  for  patients  who  are  not  confined  to  bed.  The  tub  is  filled 
so  that  the  water  at  90°  F.  reaches  the  umbilicus  of  the  sitting  patient, 
who  wears  a  wet  turban.  Tae  attendant  pours  water  upon  the  chest 
and  back  several  times.  Cold  water  is  added  so  that  the  temperature 
of  the  bath  is  reduced  to  86°  F.  The  patient  is  thoroughly  rubbed 
and  is  again  douched  on  chest  and  back;  the  entire  procedure  lasts 
three  minutes.  The  bath  temperature  is  reduced  daily  one  or  two  de- 
grees, until  82.5°  F.  are  reached,  which  is  well  borne  by  the  weakest 
patients,  except  neurasthenics,  who  do  not  bear  temperatures  below  91° 
well.  Appetite  and  sleep  are  improved.  The  treatment  is  missed  by 
poor  patients  after  their  discharge;  the  better  situated  always  continue 
it.  Half  baths  are  not  advised  in  febrile  cases,  which  are  always  im- 
mobilized; nor  are  cold  baths  advised.  The  febrile  cases  receive  wet 
compresses  around  the  trunk;  these  are  made  of  linen  and  dipped  in 
cold  water  (temperature  not  given),  wrung  out,  wrapped  around  the 
entire  trunk,  and  covered  by  flannel  (see  article  "Wet  Compress" 
for  technique).  Kuthy  has  obtained  very  calming  effects,  in  insomnia 
and  painful  conditions,  from  wringing  the  compress  out  of  very  cold 
water  and  leaving  it  several  hours  in  situ  to  produce  a  vapor  around 
the  trunk.  When  the  temperature  is  high  the  compress  should  be  less 
wrung  out  (see  article  "  Wet  Compresses  ").  Rest  in  bed  combined 
with  wet  compresses  is  far  more  valuable  than  antipyretics.  A  cold 
coil  secured  over  the  heart  enhances  the  thermic  and  cardiotonic  action. 
Another  valuable  procedure  in  febrile  cases  is  the  partial  ablution,  be- 
ginning by  uncovering  one  arm,  wrapping  it  in  a  damp  towel  and  rub- 
bing over  the  latter  until  the  skin  reddens.  The  arm  is  replaced 
without  drying;  the  other  arm,  chest,  and  back  are  similarly  treated, 
the  damp  cold  cloth  being  stretched  over  the  parts  before  the  latter 
are  rubbed.  This  procedure  is  regarded  by  Kuthy  as  "inestimable"; 
it  invigorates  and  hardens  the  patient,  improves  the  appetite,  abstracts 
heat  mildly,  improves  the  peripheral  circulation,  and  is  the  best  pro- 
tection against  sweats. 

The  typical  management  of  our  febrile  cases  is  "  rest  in  bed,  trunk 
compresses  every  two  hours,  and  every  morning  an  ablution.  We 
rarely  had  a  patient  who  did  not  improve  in  a  few  days  subjectively. 
Even  cases  of  doubtful  prognosis  frequently  improve  in  appetite  and 
general  tone,  and  the  night  sweats  are  controlled  by  an  evening  ablu- 
tion even  when  the  most  powerful  antihydrotic  medicines  fail.  When 
pityriasis,  caries,  or  lupus  affects  the  chest  or  other  parts  in  cases  of 
pronounced  depreciation  and  in  those  in  which  by  reason  of  hemorrhages 
strict  rest  must  be  enforced,  friction  over  the  arms  and  thighs,  cov- 


424       THE  PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

ered  by  a  well-stretched  damp  towel,  is  applied  with  advantage. 
There  is  no  effect  upon  haemoptysis,  but  the  comfort  of  the  patient  is 
enhanced  and  the  prognosis  improved." 

Kuthy  very  properly  does  not  apply  the  douche  as  frequently  as  do 
other  German  sanatorium  physicians, because  the  cold  douche  is  often  too 
exciting,  although  it  is  doubtless  a  good  tonic,  improves  the  heart  and 
appetite,  and  enhances  tissue  change,  hardens  the  patient,  and  ventilates 
the  lung  by  deepening  the  inspiration.  It  is  badly  borne  by  irritable 
neurasthenics,  of  which  there  are  many  cases.  By  proper  selection  of 
cases,  however,  the  majority  of  cases  may  be  benefited  by  mild 
douches,  which  he  has  used  for  many  years — water  of  95°  F.,  reduced 
gradually  as  far  as  50°  or  60°  F.,  is  well  borne.  This  observation  of 
Kuthy  confirms  my  own  observation  of  the  large  material  of  the  Mon- 
tefiore  Home  (see  opening  of  this  chapter)  in  which  I  began  with  mild 
ablutions  and  gradually  trained  the  patients  to  lower  temperatures  and 
higher  pressures  as  the  case  indicated.  Unfortunately  such  individ- 
ualization  makes  great  demands  upon  the  physician's  time  and  judg- 
ment, while  the  prescription  of  fresh  air,  good  food,  rest,  or  exercise 
are  far  more  simple.  Just  as  the  systematic  application  of  the  latter 
agents  has  wrought  the  favorable  change  in  prognosis  resulting  from 
sanatorium  management,  so  will  the  systematic  and  skilful  adaptation 
of  hydriatric  procedures  positively  improve  the  statistics  in  institutional 
and  private  practice. 

The  fan  douche  abstracts  less  heat  and  is  less  brusque  and  exciting 
than  the  rain  douche,  which  is  really  a  cold  shower.  Kuthy  justly 
dwells  upon  this  important  point  *  and  advises  the  treatment  which 
the  author  first  applied  in  the  Montefiore  Home  in  1886.  Kuthy 
justly  regards  temperatures  in  neurasthenics  one  or  more  degrees 
above  normal  and  a  tendency  to  haemoptysis  as  contraindicating 
douches.  He  recommends  cold  jet  douches  to  the  feet  to  counteract 
their  habitual  coldness,  and  prefers  them  to  hot  bottles,  etc.,  even  in 
midwinter.  He  also  has  obtained  good  results  in  insomnia  from  cold 
compresses  around  the  legs  and  thighs  and  lower  extremities.  He 
esteems  the  cold  coil  or  ice-bag  applied  over  the  cardiac  region  highly 
in  toxic  heart  failure  and  irregularity. 

*  During  a  visit  at  Falkenstein  in  1896,  the  author  was  shown  the  douche  of 
the  institution.  To  his  great  surprise  and  chagrin  he  found  it  to  consist  of  a  per- 
forated plate,  18  inches  in  diameter,  suspended  from  the  ceiling  above  a  sunken 
basin  in  the  asphalt  floor.  On  inquiring  for  the  temperature  and  pressure  of  the 
water,  it  was  discovered  that  these  were  unknown  quantities.  By  request  of 
the  author,  the  water  was  ascertained  to  have  a  temperature  of  47°  F.,  and  he 
was  informed  that  only  cases  already  improved  by  the  regular  treatment  were 
subjected  to  the  douche  to  harden  them. 


DIABETES.  425 

DIABETES. 

Diabetes  is  a  malady  which  we  are  in  the  habit  of  treating  in  an 
empirical  manner,  with  little  hope  of  restoration  to  ^health.  To  di- 
minish the  entrance  of  sugar-producing  foods  into  the  system  is  the 
leading  principle  in  the  "treatment  of  this  disease."  That  lives  have 
been  prolonged  by  strict  attention  to  diet  there  is  no  doubt.  But  how 
great  is  the  sacrifice  of  comfort  and  happiness  these  patients  are  too 
often  called  upon  to  make  when  following  conscientiously  the  rigor- 
ous dietetic  orders  few  physicians  realize,  unless  they  or  some  near 
member  of  their  family  be  a  subject  of  this  malady. 

There  is  a  method  of  managing  the  patient  in  this  disease  which  has 
been  rewarded  with  a  success  to  which  the  author  had  been  a  stranger 
during  the  first  twenty-five  years  of  his  professional  career,  and  in  the 
scheme  of  which  hydrotherapy  enters  very  largely.  We  know  that 
the  glycogenic  function  of  the  liver  is  in  abeyance  and  greatly  impaired, 
while  the  muscles,  which  also  possess  glycogenic  function,  fail  by 
reason  of  the  lassitude  incident  to  this  disease.  There  being  no  agent 
by  means  of  which  the  glycogenic  function  of  the  liver  can  be  enhanced, 
and  the  causes  of  the  loss  of  this  function  being  still  obscure,  there  is 
nothing  left  but  to  limit  the  supply  of  sugar-producing  element.  We 
are,  however,  in  a  more  favorable  position  with  regard  to  increasing 
the  functional  activity  of  the  muscles,  and  thus  enhancing  the  well- 
known  sugar-converting  function  of  their  inner  fibrillar  substance.  By 
increasing,  therefore,  the  circulation  in  the  muscles  (the  principal 
effect  of  exercise  and  touic  hydrotherapy)  we  may  enable  the  system 
to  appropriate  a  large  proportion  of  the  sugar  circulating  in  the  blood, 
and  thus  prevent  its  loss  to  the  system.  Clinical  experience  is  hap- 
pily in  entire  accord  with  this  deduction  from  physiological  observa- 
tions. The  latter  are  not  new,  but  their  true  import  is  unfortunately 
not  recognized  sufficiently  to  become  part  of  a  scheme  in  treatment. 

Diabetic  patients  are  warned  to  live  hygienic  lives,  to  keep  clean, 
and  take  plenty  of  exercise.  The  insufficiency  of  directing  such  a  pa- 
tient to  exercise  is  soon  made  evident;  he  is  unable  to  exercise  much 
without  great  fatigue.  Inasmuch  as  the  latter  is  regarded  as  detri- 
mental, less  exercise  is  ordered  and  taken  until  it  is  abandoned  alto- 
gether. 

It  has  long  been  my  custom  to  insist  upon  regular  and  sustained 
exercise,  by  which  alone  muscular  glycogenesis  can  be  stimulated. 
This  requires  great  moral  courage  and  energy.  So  great  are  the  languor 
and  inertness  of  the  patient  that  it  is  almost  impossible  to  overcome 
this.  And  here  is  the  point  where  hydrotherapy  enters  as  an  impor- 
tant remedial  agent.  That  great  physiologic  stimulant,  cold  applied 


426       THE   PRINCIPLES   AND   PEACTICE  OF   HYDROTHERAPY. 

through  the  medium  of  water,  especially  when  combined  with  the 
mechanical  stimulation  of  the  douche  or  affusion,  arouses  nerve  activ- 
ity, increases  muscular  capacity,  contracts  muscular  tissue,  improves 
nutrition  and  hsematosis,  and  thereby  increases  energy,  removes  lan- 
guor and  indisposition  to  exercise.  When  moral  suasion  has  failed, 
and  even  the  certain  prospect  of  further  invalidism  has  not  stimulated 
the  diabetic  to  effort,  the  systematic  daily  neurovascular  training  by 
the  cold  douche  or  affusion  has  often  requited  me  by  a  renewal  of  life, 
a  quickening  of  all  the  functions,  an  elevation  of  vital  activity,  which 
brought  the  patient  to  tolerate  and  even  enjoy  muscular  exercise,  with- 
out fatiguing  him.  Not  alone  do  we  thus  obtain  the  salutary  influence 
upon  the  muscular  glycogenesis,  but  the  improvement  of  the  patient's 
general  health  contributes  to  the  enhancement  of  his  digestion,  assim- 
ilation, and  more  normal  excretions;  weight  is  gained;  the  patient  and 
friends  are  cheered.  Such  stimulating  effect  upon  the  nervous  system 
in  a  disease  which  is  so  largely  neurotic  conduces  vastly  to  the  resto- 
ration of  health.  It  has  been  my  frequent  observation  that  strict  rules 
of  diet  may  be  relaxed  where  systematic  exercise,  of  which  I  insist  upon 
having  a  record  on  the  pedometer,  and  hydrotherapy  are  added  to  the 
management  of  diabetes.  Here  again  we  have  a  striking  illustration 
of  the  fact  that  hydrotherapy,  though  not  directly  curative,  aids  in 
enhancing  the  resistance  of  the  human  organism  to  disease. 

In  addition  to  this  action  of  cold  procedures,  there  may  be  a 
hitherto  unknown  stimulation  of  the  sebaceous  glands  which  may  re- 
sult in  an  accumulation  of  glycogen  in  them.  Lombardo  *  has  found 
glycogen  in  the  foetal  skin.  He  states  that  he  has  discovered  it  in 
adults,  by  a  process  which  he  details,  "constantly  in  the  secreting 
epithelium  of  the  sebaceous  glands,  and  that  it  was  more  abundant 
the  greater  the  functional  activity  of  the  glands.  It  was  also  found 
in  the  external  epithelial  layers  of  the  skin,  from  the  bulbs  to  the  in- 
sertion of  the  erector  muscle  of  the  hair." 

One  brief  clinical  history  of  a  case  of  long-enduring  restoration 
must  suffice  to  illustrate  my  statements : 

Mrs.  S. ,  aged  65  years,  consulted  me  on  March  2,  1892,  for  great 
lassitude,  loss  of  appetite,  depression  of  spirits,  and  other  symptoms 
pointing  to  diabetes.  Examination  revealed  six  per  cent  of  sugar, 
specific  gravity  1040,  quantity  in  twenty-four  hours  eighty-one  ounces. 
Weighing  nude  253  pounds,  and  being  quite  inert  and  languid,  exer- 
cise seemed  utterly  out  of  the  question.  A  strict  antidiabetic  diet  was 
prescribed  and  rigidly  adhered  to,  but  she  could  not  walk  two  blocks 
without  dyspnoea  and  great  exhaustion.  Despite  the  most  laudable 
persistence  in  her  efforts  to  carry  out  my  instructions  for  one  month 
*  La  Tribune  medicale,  Dec.,  1907. 


DIABETES.  427 

she  lost  oiily  one-half  per  cent  of  sugar.  In  order  to  reduce  her 
weight  and  improve  her  nerve  and  muscle  energy,  she  was  induced  to 
drive  in  a  carriage  five  miles  to  receive  the  following  treatment :  Once 
a  week  she  received  a  hot-air  box  bath  until  she  perspired  freely. 
This  was  followed  by  the  circular  douche  at  90°  for  half  a  minute, 
and  by  the  fan  douche  at  80°.  This  was  succeeded  by  active  massage 
and  resisting  movements  for  fifteen  minutes.  Five  times  a  week  she 
received  a  tonic  hydriatric  procedure  (beginning  with  a  dry  pack  for 
half  an  hour  for  the  purpose  of  filling  the  cutaneous  vessels,  and  fol- 
lowed by  a  general  ablution  at  70°  with  good  friction.  On  April  15th — 
i.e.,  in  two  weeks — she  had  lost  six  pounds  and  was  able  to  walk  six 
blocks  twice  a  day.  A  week  later  specific  gravity  of  urine  was  five 
points  less,  sugar  three-fourths  per  cent  less.  Wet  packs  in  sheets 
wrung  out  of  water  at  50°  were  each  given  for  forty-five  minutes,  fol- 
lowed by  half-baths  of  ten  minutes  at  85°,  with  active  friction  in  tub, 
followed  by  massage  and  resisting  movements  for  fifteen  minutes. 
The  object  of  this  procedure  was  to  increase  tissue  change  and  improve 
the  circulation  in  the  muscles.  This  effect  was  increased  a  month 
later  by  substituting  the  jet  douche  under  thirty  pounds  pressure  at 
60°  F.  for  the  half-bath.  It  was  delightful  to  observe  how  this  large 
and  unwieldy  woman  gained  in  energy,  desire  and  ability  to  walk,  so 
that  at  the  expiration  of  three  months,  despite  the  summer  heat,  she 
was  able  to  walk  four  miles  a  day,  morning  and  evening.  The  diet 
remaining  the  same,  sugar  decreased  gradually  from  the  time  she  was 
able  to  walk  a  mile  daily,  until  eight  months  after  beginning  treat- 
ment she  was  entirely  free  from  sugar.  She  was  free  from  diabetes 
eight  years  later,  the  only  precaution  being  to  resort  to  more  muscular 
exercise  when  farinaceous  food  was  indulged  in  moderately. 

Home  Treatment  may  be  quite  as  effectively  applied  as  the  institution 
treatment.  Following  the  method  described  as  Neuro- Vascular  Train- 
ing on  page  436,  and  under  Phthisis  Management,  and  cautiously  ad- 
vancing to  more  positive  cold  procedures,  from  which  the  patient  reacts 
well — affusions,  daily  lowered  in  temperature  (see  technique  on  page 
110),  Drip  Sheet,  Cold  Plunge,  the  family  physician  may  note  an  en- 
hancement of  muscular  vigor,  an  improvement  in  the  action  of  the 
skin,  a  better  appetite,  digestion  and  assimilation — an  elevation  of  the 
will  power,  and  consequent  ability  to  obey  instructions  with  regard  to 
diet  and  systematic  exercise.  The  dread  of  cold  water  will  disappear 
under  this  cautious  raising  of  the  patient's  depreciated  "tone."  All 
possible  injurious  effects  of  the  latter  may  be  effectively  neutralized 
by  making  the  applications  brief,  repeating  them  several  times  a  day 
rather  than  prolonging  them.  Good  friction  during  the  treatment  pre- 
vents chilling  after  its  conclusion. 


CHAPTER  XXIV. 

MALARIAL  DISEASES. 

ALTHOUGH  we  possess  in  quinine  a  curative  remedy  for  true  (plasmo- 
dium)  malarial  fever,  cases  do  occur  which  resist  its  influence,  or  in 
which  the  medicine  cannot  be  taken  or  retained.  Moreover,  there  are 
certain  forms  of  malarial  fevers  of  great  severity,  in  which  it  is  well- 
nigh  impossible  to  obtain  absorption  of  quinine ;  and  there  are  other 
forms  in  which  quinine  has  been  found  rather  deleterious  than  other- 
wise. The  former  are  those  chronic  forms  in  which  the  paroxysmal 
habit  has  been  set  up,  as  it  were.  This  type  of  cases  is  not  infrequent  in 
malarial  regions ;  they  usually  arise  from  neglected  cases  and  continue 
during  the  winter  .months,  despite  atmospheric  conditions  which  would 
prevent  the  recurrence  of  the  disease  de  novo.  When  medicinal,  die- 
tetic, and  climatic  treatment  have  failed  to  restore  these  cases  to  health, 
hydrotherapy  may  prevent  the  recurrence  of  the  paroxysms  and  so 
improve  the  general  health  that  a  favorable  issue  may  result. 

The  malignant  types  of  malarial  diseases,  especially  the  hemor- 
rhagic  form,  have  proven  very  rebellious  to  quinine  treatment,  prob- 
ably because  the  absorption  of  this  agent  is  rendered  difficult  by  im- 
paired circulatory  conditions.  Steudel,  *  who  is  an  enthusiastic  advocate 
of  quinine,  concedes  that  the  development  of  pernicious  forms  of  ma- 
laria failed  to  be  prevented  by  the  most  energetic  prophylactic  use  of 
quinine  in  fifty  per  cent  of  the  cases. 

Has  the  application  of  water  in  this  disease  demonstrated  its  clin- 
ical value  sufficiently  to  warrant  a  resort  to  it,  when  quinine  has  failed, 
or  when  its  application  was  inexpedient  or  impossible?  This  question 
will  be  answered  in  this  chapter. 

In  the  early  part  of  this  century  Currie  reported  that  several  times 
he  prevented  the  development  of  intermittents  by  affusions  of  cold 
water,  given  about  an  hour  before  the  expected  paroxysm ;  and  that 
four  or  five  affusions  caused  the  cessation  of  the  paroxysms. 

The  pioneer  of  scientific  hydrotherapy  in  France,  Fleury,  applied 
douches  of  55°-60°  F.,  one  or  two  hours  before  the  paroxysm  in  over 
one  hundred  cases,  and  came  to  the  following  conclusions,  which  were 
investigated  and  confirmed  by  a  royal  Belgian  commission  in  the  Mili- 
tary Hospital  at  Brussels :  1st.  In  simple  recent  intermittents,  with  or 
without  enlarged  spleen,  cold  douches  may  replace  quinine.  2d.  In 
old,  regular,  or  irregular  intermittents  with  relapses,  cachexia,  anaemia, 
etc.,  cold  douches  should  always  be  preferred  to  quinine. 

*  "Die  perniciose  Malaria  in  Deutsch-Af rika, "  Leipzig,  1897. 


MALARIAL  DISEASES.  429 

The  history  of  this  subject,  gathered  since  the  days  of  Fleury,  tends 
to  maintain  the  correctness  of  his  conclusions.  In  the  large  preponder- 
ance of  recent  (plasmodium)  malarias  quinine  is  of  undoubted  value. 
When  rightly  administered,  to  the  production  of  cinchonism,  three 
hours  before  the  expected  paroxysm,  the  effect  is  specific — the  only 
real  specific  in  therapeutics ;  we  can  predict  the  result  with  certainty. 
To  recommend  any  hydriatric  procedure  in  these  cases  is  unnecessary, 
and  its  preference  to  quinine  can  be  entertained  only  by  a  water 
enthusiast.  When,  however,  for  some  known  or  unfathomable  reason, 
quinine  is  not  absorbed  so  as  to  produce  cinchonism,  or  the  paroxysm 
is  too  irregular  in  its  return  to  be  forestalled,  the  records  show  that 
hydrotherapy  "  may  replace  it"  very  satisfactorily. 

That  quinine  should  be  replaced  by  hydrotherapy  in  the  old, 
irregular  cases,  as  Fleury  recommends,  may  at  first  thought  be  deemed 
to  be  a  water  enthusiast' s  view.  But  those  who  have,  like  the  writer, 
often  been  baffled  in  these  trying  cases  will  gladly  welcome  so  simple 
a  measure  as  a  cold  douche,  affusion,  or  hip  bath  as  a  trustworthy 
refuge  when  quinine  fails. 

The  author,  who  practised  for  fifteen  years  on  the  banks  of  the 
Water ee  River,  near  Camden,  S.  C.,  where  the  adjoining  plantations 
breed  malaria  of  the  mildest  as  well  as  the  most  malignant  type,  real- 
izes how  much  he  lost  at  that  time  by  reason  of  his  unfamiliarity  with 
this  valuable  therapeutic  function  of  water  in  malaria.  Since  his 
residence  in  New  York  he  has  had  but  one  opportunity  to  treat  an 
obstinate  case  of  intermittent  by  water,  the  relation  of  which  may  be 
instructive.  The  subject  of  the  following  history  was  saved  by  hydro- 
therapy  as  an  infant  (see  page  371). 

P.  S ,  aged  13  years,  applied  for  treatment  September  14th,  1893.  He  had 

been  suffering  from  a  quotidian  fever  since  the  summer  of  1892.  The  attack 
yielded  to  quinine  for  weeks,  but  continued  to  recur  at  the  most  unexpected  periods 
during  the  following  winter.  He  regarded  himself  cured,  paroxysms  having 
been  absent  for  several  weeks,  when  on  his  way  to  the  Chicago  Fair  he  had  a  chill 
when  crossing  Niagara  Falls  Bridge.  On  his  return  home  he  again  submitted  to 
a  course  of  quinine  and  arsenic  with  occasional  good  result.  The  paroxysm  re- 
turning in  September,  I  was  called  during  the  absence  of  his  able  medical  atten- 
dant, Dr.  W.  T.  Alexander,  and  found  that  he  had  had  several  daily  recurring 
attacks,  which  compelled  him  to  retire  from  the  schoolroom  about  11  A.M.  every 
day.  The  spleen  was  enlarged  about  one-fourth  ;  the  boy  was  anaemic  and  de- 
spondent, although  he  felt  well  during  the  early  morning  hours.  I  prescribed 
quinine,  but  failed  to  cinchonize  him,  even  with  the  solution  in  large  doses 
(20  gr. ).  About  a  week  was  thus  wasted,  when  I  advised  his  intelligent  mother 
to  give  him,  at  10  A.M.  daily,  a  cold  douche  upon  the  back,  while  standing  in 
twelve  inches  of  hot  water  in  the  bathtub.  The  boy's  residence  being  in  Audu- 
bon  Park,  on  the  eastern  bank  of  the  Hudson  River,  the  water  pressure  was  quite 
strong,  probably  thirty  pounds.  The  temperature  of  the  water  was  60° ;  the 
duration  five  minutes.  The  effect  was  simply  marvellous ;  the  boy  has  never  had 


430 

a  return  of  the  malarial  paroxysm  since  the  first  douche ;  the  latter  was  con- 
tinued daily  for  one  month,  and  he  was  advised  to  take  cold  plunges  daily  dur- 
ing the  winter.  His  health  was  completely  restored. 

This  experience  has  been  frequently  repeated  by  others.  Fodor* 
reports  seven  cases  of  malarial  fever,  from  five  weeks'  to  four  years' 
duration,  which  had  been  treated  with  quinine  secundem  artem  without 
success,  and  which  yielded  to  douches  and  hip  baths  very  rapidly. 
These  and  other  histories  recorded  by  Fischer,  Strasser,  and  others, 
are  remarkable  for  minuteness  of  description  and  for  the  rapid  effect 
of  the  treatment  which  they  record. 

Alois  Strasser, t  in  detailing  one  of  these  cases,  offers  the  following 
explanation  of  the  rationale  of  hydriatric  procedures  in  malarial  affec- 
tions. "  Quinine  and  hydrotherapy  act  alike  by  rendering  the  plasmo- 
dium  harmless.  Quinine  destroys  the  plasmodium,  or  so  weakens  it 
that  sporulation  and  reproduction  are  inhibited.  The  natural  course 
of  the  paroxysm  consists  of  the  entrance  of  the  parasite  into  the  blood 
current,  its  growth  in  the  red  cells,  the  destruction  of  the  latter  and 
of  the  parasite,  and  the  admixture  of  the  products  of  this  decay  with 
the  leucocytes.  Cold  applications  act  by  causing  a  breaking  down  of 
the  red  cells,  which  have  been  weakened  by  containing  the  plasmodia 
in  the  act  of  breaking  up,  before  the  fever  occurs,  and  by  furthering 
destruction  of  the  plasmodia  which  have  left  the  cells,  either  by  phago- 
cytosis or  by  increased  oxidation." 

Quinine  is  supposed  by  Binz  and  others  to  destroy  the  parasite 
itself,  but  cold  water  can  act  only  by  enhancing  the  normal  antipara- 
sitic  power  of  the  blood  serum,  the  tissues,  and  the  cells  of  the  organ- 
ism. Cold  water  acts  as  a  whip,  which  drives  the  latter  to  the  highest 
development  of  its  reactive  capacity.  The  vital  energies  are  height- 
ened; the  action  of  the  heart,  lungs,  and  skin  is  excited.  The  resist- 
ing and  bactericidal  power  of  the  cell  is  enhanced.  This  increased  ca- 
pacity for  work  is  evidenced  by  the  rise  of  alkalescence  of  the  blood  and 
by  the  mobilization  of  leucocytes  circulating  in  it  after  cold  procedures. 

The  aborting  of  a  malarial  paroxysm  by  cold  water  may  be  ex- 
plained by  the  fact  that  the  chill  is  really  a  retention  fever,  in  which 
the  contraction  of  the  peripheral  vessels,  which  gradually  reaches  a 
high  degree,  prevents  the  giving  off  of  heat  from  the  skin.  Maragliano 
has  shown  that  this  contraction  of  the  peripheral  vessels  begins  two 
hours  before  the  temperature  begins  to  rise-  The  retention  of  heat  is 
therefore  colossal,  not  only  in  malarial,  but  in  other  fevers  beginning 
with  chills.  By  an  artificial  removal  of  this  contraction  of  the  per- 
ipheral vessels  we  may  remove  the  heat  retention  and  abort  the 
paroxysm.  If  this  is  done  two  hours  before  the  latter  is  due,  it  may 

*  Blatter  ftlr  klinische  Hydrotherapie,  p.  139,  1892,  and  1895. 
t  Ibid.,  p.  19,  1894,  and  p.  190,  1897. 


MALARIAL   DISEASES.  431 

be  prevented  entirely.  The  cold  procedure  is  most  efficient  for  the 
purpose  of  dilating  the  cutaneous  vessels  by  the  reaction  which  ensues; 
the  more  thorough  the  latter  is,  the  better  the  result,  especially  if  per- 
spiration is  promoted  by  exercise  when  the  patient  is  able  to  take  it. 

We  have,  therefore,  a  double  effect  for  cold  procedures  before  the 
paroxysm,  namely,  the  furtherance  of  destruction  of  the  red  cells 
which  have  acted  as  hosts  for  the  plasmodium,  and  the  removal  of  the 
detritus  of  both  by  enhanced  oxidation  and  eliminative  action,  and  by 
counteracting  heat  retention. 

Strasser  cites  two  hundred  and  seventy- two  cases  of  malarial  fever, 
which  have  been  treated  successfully  by  hydriatric  procedures,  by  sev- 
eral reporters. 

The  procedures  which  have  been  found  most  useful  are  as  follows: 
By  careful  investigation  the  time  of  the  expected  paroxysm  must  be 
ascertained.  About  an  hour  before  the  time,  a  douche  should  be  ap- 
plied, preceded  if  possible  by  a  dry  pack  or  hot-air  bath.  The  patient, 
standing  in  water  at  100°,  receives  over  the  spleen,  liver,  and  spine  a 
douche  or  affusions  of  60°  or  less,  lasting  thirty  to  fifty  seconds,  with 
the  object  of  producing  decided  reaction  after  the  shock.  This  should 
by  repeated  in  half  an  hour,  to  insure  proper  effect.  In  many  in- 
stances the  treatment  will  prevent  the  paroxysm.  Whether  it  does  so 
or  not,  it  should  be  repeated  every  day  at  the  same  time  for  a  week 
or  two. 

If  the  paroxysm  develops,  the  full  bath  at  75°,  wet  pack  at  65°,  or 
ablution  at  60°,  with  abdominal  compresses  at  60°,  should  be  applied  for 
antifebrile  purposes.  The  chief  purpose,  however,  should  be  the  pre- 
vention of  the  paroxysm  by  a  daily  cold  douche,  repeated  twice  within 
an  hour  of  the  expected  paroxysm. 

Relapses  have  been  produced  by  cold  douches  under  Strasser' s  ob- 
servation. He  explains  these  by  the  contrasting  effect  upon  the  spleen 
which  his  onkometric  experiments  have  brought  out.  The  plasmodia 
which  have  probably  been  lodged  in  the  spleen  are  thus  driven  into 
the  circulation  and  their  activity  receives  full  scope  for  baneful  action. 

The  success  of  affusions  with  buckets  of  cold  water  in  the  malignant 
type  of  malarial  fever  has  been  reported  by  Southern  and  Western 
physicians  residing  in  the  dangerous  alluvial  bottoms  of  the  Mississippi 
and  other  rivers.  The  older  text-books (Geo.  B.  Wood's  "Practice," 
1866)  may  be  profitably  consulted  on  this  fact. 


CHAPTER  XXV. 

NEURASTHENIA. 

BY  consensus  of  many  authorities,  hydrotherapy  is  indispensable  in 
the  management  of  the  large  majority  of  neurasthenics.  Indeed,  there 
is  probably  no  chronic  disease  in  which  its  application  contributes  more 
largely  to  the  betterment  of  the  patient's  condition  and  which  renders 
the  effect  of  changed  environment,  removal  of  etiological  factors,  diet, 
electricity,  and  medication  more  pronounced  and  enduring. 

Long  before  neurology  had  become  a  specialty  or  neurasthenia  had 
been  recognized  by  our  own  Beard  as  a  distinct  disease,  Griffin*  pre- 
scribed lukewarm  and  cold  ablutions  in  "  spinal  irritation." 

Rombergf  advised  cold  affusions  over  the  head  for  vertigo,  and  rec- 
ommended warmly  a  systematic  cold-water  treatment  for  cases  of 
"psychical  hypersesthesia." 

Preiss  J  said  truly,  long  ago :  "  Prolonged  continuance  of  anom- 
alies of  the  nervous  system  not  rarely  derange  important  functions, 
including  those  of  the  chylopoietic  organs.  Since  all  functions  de- 
pend upon  nerve  action,  and  no  other  remedy  is  capable  of  altering 
the  nervous  system  in  a  mild  manner  so  rapidly,  surely,  easily,  and 
thoroughly  as  water,  this  simple  remedy  must  occupy  the  first  rank  as 
a  nerve  tonic." 

Eulenburgg  regards  balneotherapeutic  procedures  in  the  form  of 
cold-water  treatment  among  the  most  important  agents. 

Jolly  prefers,  in  his  treatment  of  hypochondriasis,  hydrotherapy 
to  electrotherapy.  He  recommends  the  consumption  of  large  quantities 
of  water  to  promote  renal  and  peristaltic  action,  and  regards  the 
external  application  of  water  as  very  useful  "  in  those  cases  in  which 
increased  excitability  is  combined  with  tendency  to  exhaustion. "  Jolly 
regards  this  favorable  influence  due  to  the  cutaneous  derivation  and 
improvement  in  the  circulation  and  tone  of  the  vessels,  as  produced  by 
cold  rubs,  half  and  full  baths  with  friction  and  douches,  always  care- 

*  "  Observations  on  Functional  Affections  of  the  Spinal  Cord  and  Gang 
lionic  System  of  Nerves, "  London.  1834 

f  "Lehrbuch  der  Nervenkrankheiten  des  Menschen,"  Berlin,  1851,  p.  20. 

j  "  Physiologische  Untersuchungen, "  Berlin,  1858. 

§  "Lehrbuch  der  Nervenkrankhei ten,"  1878,  vol.  ii.,  p.  697. 


NEURASTHENIA.  433 

fully  adapting  the  temperature,  etc.,  to  the  patient's  condition.  He 
advises  sending  obstinate  cases  to  institutions  where  treatment  may  be 
applied  judiciously. 

Krafft-Ebing*  writes :  "  In  the  management  of  neurasthenia  the 
water  treatment  is  of  the  greatest  value,  because  as  applied  preferably 
in  institutions,  it  admits  of  all  possible  excitant,  calming,  and  alterative 
effects  upon  the  diseased  organism  and  its  tissue  change. "  He  recom- 
mends hydrotherapy  in  insomnia,  and  regards  its  good  effect  in  neu- 
rasthenia as  due  to  regulation  of  cardiac  activity,  dilatation  of  peri- 
pheral vessels,  diminution  or  increase  in  the  cerebral  circulation,  general 
calming,  etc.,  according  to  the  procedures  used,  and  which  he  carefully 
indicates. 

Strumpell  prefers  to  send  severe  cases  of  neurasthenia  to  institu- 
tions. He  advises  cold  rubs,  half-baths,  and  douches  upon  the  loins. 

Bouchutf  uses  most  hydriatic  measures,  but  advises  that  the 
physician  familiarize  himself  with  them,  and  exercise  great  caution  in 
their  application.  He  emphasizes  that  the  skin  is  invigorated,  tissue 
change  stimulated,  and  haematosis  enhanced.  He  furnishes  many 
clinical  histories  to  illustrate  the  effect  of  hydrotherapy. J 

Erb§  says :  "  Cold  and  cool  baths,  the  application  of  cold  water 
in  its  various  forms,  belong  to  the  most  important  and  most  active 
agents  in  the  treatment  of  nervous  diseases.  Its  results  in  all  possible 
forms  of  chronic  nervous  diseases  are  extraordinarily  favorable.  It  is 
evident  that  we  possess  few  remedies  which  produce  an  equally  power- 
ful effect  upon  the  nervous  system." 

Klemperer,  ||  chief  of  Professor  Leyden's  clinic  in  the  Berlin  Uni- 
versity, says :  that  "  in  hydrotherapeutic  effects  we  observe  quite  an 
extraordinary  and  incomparable  stimulation  of  the  nervous  system 
which  is  reflected  upon  the  various  organs." 

Dr.  William  H.  Draper  ^[  says :  "  In  persons  whose  nutrition  has 
been  enfeebled  by  chronic  disease  and  in  neurasthenia,  hysteria,  and 
hypochondriasis,  its  good  effects  are  very  striking.  It  seems  to  be  more 
effective  than  any  treatment  by  medicine  in  stimulating  the  nerve  centres, 
in  restoring  the  equilibrium  of  the  circulation,  and  reviving  the  activ- 
ity of  the  organic  functions. 

"  Its  best  results  require  the  appurtenances  of  a  well-ordered  estab- 
lishment, where  all  the  various  methods  of  applying  water  can  be 
wisely  and  skilfully  directed." 

*"Ueber  gesunde  und  kranke  Nerven,"  p.  146. 
f  "  Du  Nervosisme, "  p.  350. 

j  "  Handbuch  der  Neurasthenie, "  F.  C.  Muller,  1895. 
§Ziems8en's  "Cyclopaedia." 
B  Publications  of  Hufeland  Society,  1896. 
T[  Medical  Record,  April  22d,  1893. 
28 


434        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

Dr.  Frederick  Peterson,*  chief  of  the  clinic  on  nervous  diseases  at 
the  College  of  Physicians  and  Surgeons,  holds  that  the  "  water  treat- 
ment certainly  has  many  features  which  appeal  strongly  to  our  sense 
of  rational  treatment.  Who  can  calculate  to  what  degree  we  may  thus 
influence  the  biochemical  processes  of  the  body,  the  metabolism  of  tis- 
sues, the  carrying  off  of  degenerated  and  toxic  substances,  or  deter- 
mine how  much  we  may  affect  the  vascular  neuroses,  the  local  anemias 
and  hypersemias  of  the  brain  and  spinal  cord? 

"  With  reference  to  general  nervous  diseases,  I  am  sure  there  is  a 
tendency  everywhere  among  neurologists  to  look  with  more  and  more 
complacency  upon  this  means  of  treatment  as  one  of  great  value.  I 
know  that  this  is  true  in  all  parts  of  Germany,  Austria,  and  France. 
In  some  conversations  with  Professor  Winternitz,  of  Vienna,  I  learned 
that,  in  his  practice  of  over  thirty  years,  fully  three-fourths  of  his 
patients  were  sufferers  from  nervous  disorders,  and  his  remarkable  suc- 
cess in  relieving  and  curing  bad  cases  is  everywhere  attested." 

These  comments  upon  the  value  of  hydrotherapy  in  neurasthenia 
(and  other  neuroses)  are  not  cited  from  hydrotherapists,  but  from 
writers  and  teachers  on  neurology ;  they  have  been  selected  in  order  to 
demonstrate  that  the  charge  of  "unwarranted  enthusiasm,"  which  is  so 
often  made  against  the  advocates  of  hydrotherapy,  is  unfounded  in  fact. 

In  order  clearly  to  outline  the  hydriatic  treatment  which  I  regard 
as  the  most  useful  in  neurasthenia,  it  will  be  necessary  to  divide  the 
cases  into  three  classes,  viz. :  the  torpid  or  hypochondriacal,  the  excit- 
able or  hypersesthetic,  and  the  intermediate  or  mixed  type. 

1.  The  torpid  type  has  been  most  frequently  under  my  observation 
among  the  cases  referred  for  hydrotherapy  by  colleagues,  especially 
among  those  sent  by  neurologists.  The  reason  is  probably  to  be  sought 
in  the  fact  that  these  cases  do  not  yield  so  readily  to  domestic  treat- 
ment as  the  excitable  type.  Moreover,  the  prognosis  with  regard 
to  hydrotherapy  depends  much  upon  the  patient's  blood  state.  The 
depressed  neurasthenic,  agoraphobic,  nosophobic,  or  hypochondriac 
responds  more  readily  to  treatment  than  the  hy peraesthetic  neurasthenic ; 
and  both  will  respond  better  to  hydrotherapy  if  the  general  nutrition 
and  hsematosis  are  decidedly  impaired. 

A  somewhat  extensive  acquaintance  with  the  literature,  together 
with  clinical  observation  of  the  enormous  material  received  in  the 
Park  Avenue  Hydriatric  Institute,  which  receives  private  patients,  and 
in  the  Hydriatric  Department  of  the  Eiverside  Baths,  which  receives 
patients  from  several  large  city  dispensaries,  and  of  the  Clinic  of  Co- 
lumbia University  has  convinced  me  that  many  of  the  manifestations 
*  American  Journal  of  the  Medical  Sciences,  February,  1893. 


NEURASTHENIA.  435 

of  neurasthenia  in  the  large  majority  of  cases  are  traceable  to  de- 
fective nutrition  of  the  cortical  structure,  arising  from  circulatory 
disturbances  in  the  cerebro-spinal  sphere.  Since  this  view  is  en- 
tirely clinical,  and  I  may  say  empirical,  i.e.,  based  upon  observ- 
ing the  effect  of  treatment,  I  shall  not  here  venture  upon  the 
theoretical  basis  for  my  belief.  Inasmuch  as  many  excellent  authori- 
ties, as  Beard,  Erb,  Axenfeld,  Bouchut,  Eulenburg,  Krafft-Ebing,  and 
Strumpell,  confirm  this  view  more  or  less,  it  requires  no  further  discus- 
sion in  this  practical  work  to  establish  the  remarkable  effect  of  a  judi- 
cious application  of  water,  carefully  observed  by  the  medical  attendant 
in  each  individual  and  modified  according  to  its  effect  upon  the  pulse, 
blood  pressure,  corpuscular  elements  of  blood,  etc.  The  best  authori- 
ties insist  upon  a  careful  technique,  and  yet  the  latter  is  too  often 
neglected.  Directing  the  patient  to  take  a  cold  sponge  bath  every  day, 
or  trickle  cold  water  down  his  back,  or  to  take  a  cold  plunge  bath,  or 
a  warm  bath  gradually  cooled,  or  a  Charcot  douche,  does  not  suffice  to 
obtain  the  best  results.  The  experienced  neurologist  may,  and  doubt- 
less does,  by  watching  his  patients  closely,  succeed  in  restoring  health 
by  adding  such  perfunctory  hydrotherapy  to  his  other  treatment.  But 
how  often  are  such  patients  seen  only  once  a  week  or  less  frequently, 
and  how  much  mischief  may  be  done  the  patient  by  leaving  him  for 
several  days  to  his  own  or  to  some  nurse's  water  treatment?  The 
writer  has  observed  a  case  of  "  insomnia"  of  two  years'  standing  which 
had  been  unsuccessfully  treated  by  justly  eminent  physicians  in  Ger- 
many and  in  New  York,  including  the  most  active  hydrotherapy. 
The  patient  also  failed  to  recover  under  the  most  judicious  rest  cure, 
and,  being  referred  to  the  author  by  Dr.  Wharton  Sinkler  for  water 
treatment,  began  to  improve,  and  he  eventually  recovered  entirely 
under  hydrotherapy,  which  was  assiduously  watched  every  day  and 
modified  to  suit  existing  conditions. 

I  have  recently  returned  a  patient  to  San  Francisco  in  perfect  con- 
dition after  a  three-years'  peregrination  from  one  specialist  to  another, 
from  asylum  to  sanatorium,  from  rest  cure  to  diversion.  This  case 
(psychopathic)  recovered  under  a  gradually  adapted  hydrotherapy. 

Hydrotherapy  often,  alas!  too  often,  fails,  as  do  other  remedial 
measures,  but  it  is  the  author's  belief  that  failure  of  the  former  is 
often  the  result  of  imperfect  and  unsystematic  application  by  the 
patient,  his  friends,  or  by  untrained  attendants,  of  a  treatment  which 
may  have  been  carefully  ordered  by  the  physician.  I  plead  for  the 
same  watchfulness  in  chronic  diseases  which  the  physician  maintains 
in  acute  life-endangering  maladies.  Results  approximating  those  so 
commonly  obtained  in  the  latter  may  by  assiduous  care  not  infrequently 
be  reached  in  the  former.  The  observation  of  this  fact  must  be  my 
apology  for  entering  somewhat  minutely  into  the  hydriatric  methods  I 
have  found  most  useful  in  neurasthenia. 


436        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

In  neurasthenia  of  the  torpid  type  of  patients  whose  nutrition  is 
below  par,  the  object  of  treatment  is  the  elevation  of  the  general  nutri- 
tion. If  the  patient  has  not  been  accustomed  to  cold  water  in  any 
form,  he  may  receive  a  dry  or  alcohol  rub  every  morning  before  rising ; 
a  brief  exposure  of  successive  parts  of  the  body  to  the  air  is  useful, 
and  aids  the  effect  of  the  dry  rub  or  rubbing  with  a  bath  glove  or  wash 
rag,  wrung  out  of  equal  parts  of  alcohol  and  water  at  75°  (alcohol 
being  added  to  allay  these  patients'  frequent  fear  of  cold  water),  in 
bringing  about  a  cutaneous  hypersemia.  After  continuing  these  rub- 
bings several  days,  the  patient  will  be  prepared  for  the  dry  pack  and 
ablutions  (see  page  413)  gradually  reduced  in  temperature.  This 
treatment  " feels  the  patient's  hydriatric  pulse, "  as  it  were;  for,  if 
he  reacts  well,  and  is  not  excited  by  the  procedure,  we  may  at  once 
advance  to  more  decided  measures.  In  domestic  practice  the  wet  pack, 
always  followed  by  the  half -bath,  provided  a  trained  attendant  may  be 
obtained,  is  perhaps  the  most  useful  procedure,  but  long  training  of  the 
reaction  is  required  ere  the  patient  is  able  to  bear  so  decided  a  proce- 
dure. The  shower  bath,  which  usually  has  insufficient  pressure  and  is 
but  too  frequently  applied  over  the  head,  is  "  a  delusion  and  a  snare." 
The  drip  sheet  and  cold  rub  are  very  useful  domestic  procedures  if 
applied  by  a  skilled  attendant.  It  should  always  be  remembered  that 
the  patient  requires  mechanical  aid  from  an  attendant  to  bring  about 
the  proper  reaction,  and  that  the  stimulus  conveyed  to  the  central 
nervous  system  is  the  aim  of  the  procedure.  This  point  must  never  be 
lost  sight  of.  The  depressed  patient  may  find  all  kinds  of  hypercriti- 
cal objections  to  the  treatment;  these  should  lead  the  physician  to 
observe  the  patient  if  possible  before,  during,  and  after  the  treatment, 
to  examine  the  pulse  by  the  sphygmograph  and  count  the  respiration, 
ascertaining  by  dermography  the  capillary  cutaneous  reaction ;  and,  if 
possible,  the  blood  should  be  examined  by  the  haematocrit  and  hsemom- 
eter.  Thus,  and  thus  alone,  may  the  physician  satisfy  himself  of  the 
correctness  of  the  patient's  estimate  of  the  treatment;  he  will  find  the 
latter  usually  unreliable;  and  the  nurse's  impression  is  not  always  a 
trustworthy  guide. 

Another  very  useful  procedure,  applicable  chiefly  in  cases  present- 
ing psychic  manifestations,  is,  according  to  Strumpell,  whose  observa- 
tion the  author  can  confirm,  the  hip  bath.  My  usual  practice  is  to  raise 
the  patient's  general  nutrition  by  the  procedures  above  referred  to, 
and  when  this  is  accomplished  to  order  a  hip  bath  of  90°,  daily  reduced 
one  degree  until  80°  is  reached,  of  five  to  eight  minutes'  duration, 
with  good  friction,  terminated  by  three  affusions  upon  the  back  with  a 
pitcher  or  basin  of  water  at  75°,  daily  reduced  until  60°  is  reached. 
In  addition,  the  patient  is  advised  to  consume  daily  three  portions  of 


NEURASTHENIA.  437 

eight  ounces  each  of  cold  boiled  water,  containing  as  a  placebo  and 
reminder  a  tablet  of  lithia  or  other  alkali.  Two  or  three  times  weekly 
a  thorough  intestinal  irrigation,  which  removes  all  faecal,  gaseous,  and 
other  accumulations,  enhances  the  favorable  effect  of  the  other  hydri- 
atic  measures  and  disinfects  the  intestinal  canal. 

If  this  treatment  does  not  restore  the  patient,  his  diet,  exercise,  rest, 
etc.,  being  carefully  adjusted  to  indications,  a  more  active  method 
should  be  adopted.  The  general  or  spinal  (Charcot)  douche  (one  or  both) 
is  the  most  powerful  agent  for  arousing  the  lethargic  patient,  stimu- 
lating his  nerve  centres,  and  increasing  cardiac  vigor  and  tissue  change. 
(See  Rationale  of  Douche,  page  255.)  This  procedure,  like  all  others, 
must  be  gradually  and  carefully  adapted  to  the  requirements  of  the 
case,  until  the  lowest  temperature  and  highest  pressure  are  borne  with- 
out flinching.  I  have  often  succeeded  in  training  the  patient's  reac- 
tive capacity  to  accept  a  jet  douche  of  40°  for  twenty  seconds,  under 
thirty-five  pounds'  pressure,  or  the  Scotch  douche,  which  is  the  most 
stimulating  procedure.  My  usual  course  is  to  place  the  patient  in  the 
hot-air  cabinet,  for  the  purpose  of  improving  his  reactive  capacity  by 
dilating  the  cutaneous  vessels.  He  is  removed  before  he  perspires. 
Once  a  week  he  is  allowed  to  perspire  five  minutes  for  the  purpose 
of  enhancing  tissue  change.  After  removal  from  the  cabinet  the 
patient  receives  a  circular  douche  of  one-half  to  one  minute's  duration 
at  95°,  gradually  reduced  to  85°,  to  avoid  too  great  shock  from  the 
subsequent  procedure.  A  general  fan  douche,  under  twenty  pounds' 
pressure,  follows  at  85°,  reduced  gradually  during  ten  to  twenty  sec- 
onds to  80° ;  the  latter  daily  reduced  one  degree.  The  patient  is  now 
rapidly  dried  and  sent  out  into  the  open  air  for  a  walk,  which  he  is 
ordered  to  continue  until  somewhat  fatigued.  After  one  week  of  this 
treatment  a  fan  douche  to  the  back  is  added,  beginning  with  twenty 
pounds'  pressure,  at  a  temperature  of  75°  for  five  seconds,  and  increas- 
ing pressure  and  duration  and  decreasing  temperature  daily.  This  is 
administered  after  the  circular  douche,  and  followed  by  the  general  fan 
douche  for  fifteen  seconds,  at  78°,  daily  reduced,  and  at  thirty  pounds' 
pressure.  Then  the  jet  douche  to  the  back  is  substituted  for  the  fan 
douche. 

The  prescription  at  the  beginning  of  the  third  week,  provided  the 
treatment  is  found  appropriate  to  the  patient's  reactive  capacity  (not 
to  his  own  ideas),  will  read  as  follows: 

5.  Hot-air  bath  to  beginning  perspiration.  Circular  douche,  25 
Ibs.  pressure,  1  min.,  95°-80°.  Jet  douche  back,  30  Ibs.,  5  sec.,  75°, 
daily  reduced  one  degree.  General  fan  douche,  30  Ibs.,  20  sec.,  78°, 
daily  reduced  one  degree.  Friction.  Walk  slowly  in  the  open  air. 

Owing  to  the  cumulative  effect  of  this  neurovascular  training,  daily 


438        THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

treatment  is  preferable.  Usually  Sunday  is  omitted  for  city  patients, 
but  included  for  extramural  patients  whose  stay  is  limited. 

As  the  patient's  reaction  is  improved,  less  friction  is  used  in  dry- 
ing; he  may  be  lightly  dried  and  allowed  to  clothe  himself  and  take 
active  exercise. 

Well-nourished  neurasthenics  of  the  depressed  type  are  more  difficult 
to  cure.  In  these  cases  the  patient's  response  to  water  treatment  must 
be  ascertained  in  the  manner  above  mentioned,  the  difference  being 
that  the  dry  pack  is  continued  until  the  patient  perspires  well,  which 
may  be  facilitated  by  copious  drinking  of  cold  water.  Successive  parts 
of  the  body  are  cautiously  exposed  and  well  dried  before  ablutions  are 
begun  (see  Ablutions").  The  succeeding  treatment  is  the  same  as  above, 
with  the  exception  that  the  patient  is  allowed  to  remain  in  the  hot-air 
bath  until  he  has  perspired  five  to  twenty  minutes.  If  the  patient's 
weight  is  reduced  too  much  by  this  treatment,  the  hot-air  bath  may 
either  be  shortened,  discontinued,  or  brought  only  to  cutaneous  warm- 
ing. The  internal  use  of  water  should  be  increased  to  four  portions  of 
water,  eight  ounces  each,  an  hour  before  meals  and  at  bedtime,  two 
being  hot  and  two  cold  water.  Intestinal  irrigation  is  also  an  essential 
part  of  this  treatment. 

2.  The  irritable  or  hypercesthetic  neurasthenic  does  not  offer  so 
favorable  a  field  for  hydrotherapy  as  the  opposite  type.  Here,  again, 
it  is  necessary  to  differentiate  in  our  procedures  between  the  poorly 
and  the  well-nourished  individual.  Both  types  require  very  cautious 
management.  The  dry  pack  may  "set  him  wild;"  he  objects  to  being 
confined  in  it  and  fears  lest  he  may  be  burned  or  otherwise  injured. 
This  is  not  an  uncommon  incident  with  other  patients ;  it  must  be  met  by 
quieting  assurance  from  the  constant  presence  of  a  calm  and  self-pos- 
sessed nurse.  The  hot-air  bath  also  has  terrors  for  many  patients  of 
this  type.  It  is  difficult  to  persuade  them  to  go  into  it ;  but  patience 
and  the  presence  of  other  patients  in  the  adjoining  cabinets  usually 
overcome  such  fears. 

The  patient  requires  only  a  slight  warming  up  before  he  is  subjected 
to  a  circular  douche  with  fifteen  pounds'  pressure,  for  one  minute,  at 
95°.  He  is  now  dried  without  being  rubbed,  and  sent  home  to  rest  an 
hour.  Walking  slowly  in  the  open  air  immediately  after  the  treatment 
is  far  better  than  resting  in  a  warm  room  before  returning  home,  when 
he  will  probably  be  inclined  to  sleep.  The  temperature  of  the  circular 
douche  is  reduced  daily  one  degree,  until  80°  is  reached.  In  these 
cases  strong  pressure  and  low  temperature  are  not  tolerated  ;  nor  is  active 
friction  so  useful  as  in  the  first  type.  Prolongation  of  the  treatment 
by  adding  a  fan  douche  one  degree  lower  than  the  lowest  temperature 
of  the  circular  douche,  and  with  five  pounds'  more  pressure,  will  be  all 


NEURASTHENIA.  439 

such  patients  may  bear  without  increasing  excitability.  A  gradual 
increase  of  pressure  is  better  borne  than  a  lowering  of  temperature. 
Occasionally  the  fan  douche  may  be  applied  to  the  back  as  low  as  75° 
for  one  or  two  seconds  as  a  tonic,  and  if  well  borne  repeated  oftener. 
Home  water  treatment  is  apt  to  aggravate  such  cases,  unless  given 
by  thoroughly  trained  nurses  and  unceasingly  watched  by  the  phy- 
sician. 

The  well-nourished  hypersesthetic  neurasthenic  may  begin  with 
half-baths  at  95°  for  ten  minutes,  daily  reduced  one  degree  until  85° 
is  reached.  Affusions  may  excite  him,  and  must  therefore  be  omitted 
or  gently  and  gradually  added.  Hip  baths  at  90°  for  eight  minutes  at 
bedtime  are  useful,  the  feet  being  kept  warm  and  the  bed  linen  warmed 
during  the  bath.  The  water  temperature  may  be  reduced  daily  ac- 
cording to  tolerance.  Increase  of  duration  of  the  bath  is  more  effective 
than  decrease  of  water  temperature.  This  type  of  neurasthenics  is 
the  bane  of  the  hydrotherapist,  because  the  treatment  must  be  ad- 
vanced very  slowly,  and  changed  often  according  to  its  effect  upon 
these  impressionable  individuals.  These  patients  are  almost  certain 
to  abandon  it  before  the  proper  procedure  has  been  sufficiently  tried, 
a  not  uncommon  occurrence  with  all  neurasthenics. 

A  very  prevalent  error  in  the  treatment  of  all  neurasthenics  is 
committed  in  yielding  to  the  patient's  inclination  to  have  local  treat- 
ment. He  wants  applications  to  his  head  for  headaches,  to  his  stomach 
for  dyspeptic  symptoms,  to  his  spine  for  "  spinal  pains, "  to  his  perineum 
for  "impotence,"  etc.  Such  applications  fix  his  mind  more  firmly 
upon  his  real  or  imaginary  ills  and  tend  to  aggravate  them.  He  should 
be  firmly  informed  that  he  has  lost  his  "  nerve  equilibrium, "  that  these 
ailments  are  but  manifestations  of  the  latter,  and  that  the  object  of 
the  treatment  is  a  restoration  of  the  "nerve  tone,"  and  must  therefore 
be  of  a  general  character.  Exceptions  to  this  rule  may  be  made  in 
cardiac  neurasthenia,  when  bradycardia  or  tachycardia  with  feeble 
pulse,  etc.,  are  pronounced.  Here  the  ice  coil  (see  page  149)  is  often 
useful,  applied  for  periods  of  half  an  hour  and  intermitted  for  fifteen 
minutes.  The  quieting  and  slowing  effect  of  such  a  procedure  on  the 
pulse  is  sometimes  striking  and  helps  the  patient  materially  by  sugges- 
tion, in  removing  his  apprehension  of  heart  disease. 

The  wet  pack,  60°-70°,  followed  by  the  half-bath,  80°,  for  five 
minutes,  is  perhaps  the  most  valuable  procedure  in  cardiac  neuras- 
thenia, in  which  douches  with  strong  pressure  and  low  temperatures 
must  be  avoided. 

3.  Intermediate  or  Mixed  Cases. — A  large  proportion  of  neuras- 
thenics cannot  be  classed  with  either  the  irritable  or  depressed  types. 

The  initiatory  procedures  are  ablutions,  affusions,  half-baths  as  in 


440        THE   PRINCIPLES   AND   PRACTICE   OF   HYDKOTHERAPY. 

the  other  types.  We  have  a  valuable  resource  in  the  wet  pack  at 
65°-70°,  followed  by  affusions  at  75°-85°,  or  the  circular  douche  at 
90°  for  one  minute,  and  by  the  fan  douche  at  85°,  reduced  gradually 
every  day,  but  not  below  60°.  When  the  case  partakes  more  of  one 
or  the  other  type  described  above,  the  wet  pack  may  be  advanta- 
geously followed  by  the  treatment  detailed  for  the  respective  types,  or 
it  may  be  alternated  with  the  hot-air  bath  and  douche  treatment. 

The  experiments  of  Max  Schtiller  and  the  observations  of  Mary 
Putnam  Jacobi  have  so  clearly  demonstrated  the  calming  influence  of 
the  wet  pack  upon  the  cerebral  circulation  that  we  have  an  exact  basis 
upon  which  this  treatment  may  be  applied  in  many  cases  of  neuras- 
thenia, especially  those  troublesome  cases  in  which  insomnia  is  a  pro- 
nounced manifestation. 

This  procedure  is  one  of  the  most  effective  means  of  quieting  the 
entire  nervous  system,  whether  the  irritable  condition  be  due  to  an 
essential  increase  of  reflex  excitability  or  to  a  cerebral  hyperaemia. 
The  pronounced  sinking  of  the  brain  substance,  the  positive.diminu- 
tion  of  the  respiration  and  heart  beat,  the  weakening  of  reflex  excita- 
bility and  of  activity  of  the  cerebral  ganglia  observed  in  trephined  rab- 
bits during  the  wet  pack,  combined  with  the  positive  diminution  of  the 
vessels  of  the  pia  mater,  represent  the  fundamental  conditions  for 
psychical  calm  and  sleep  These  are  probably  also  present  during  the 
wet  pack  in  man.  Sleep  is  accompanied  by  a  decided  diminution  of 
blood  in  the  cerebral  vessels ;  indeed  the  latter  has  been  accepted  as  an 
essential  condition  for  the  production  of  sleep.  This  may  explain  why 
the  wet  pack,  properly  applied,  is  a  useful  procedure  in  the  insomnia  of 
neurasthenics.  Sleeplessness  probably  depends  in  most  instances  upon 
abnormal  hypersemia  of  the  cerebral  cells,  or  upon  abnormal  vascular 
instability  or  a  more  or  less  morbid  condition  of  the  nutrition  of  the 
cerebral  cells.  When  sleep  is  vainly  sought,  these  vascular  conditions 
probably  become  emphasized.  Dwelling  upon  his  wakefulness  and  its 
possible  serious  consequences,  which  he  magnifies,  the  patient  becomes 
a  prey  to  apprehensions  of  evil.  This  mental  state  enhances  the  brain 
disturbance.  As  has  been  shown,  the  wet  pack  is  calculated  to  contrib- 
ute to  cerebral  calm  by  diminishing  peripheral  exciting  influences. 
The  interdependence  of  the  cerebral  functions  with  the  condition  of  the 
sensory  end  organs  is  well  known ;  the  perfect  functionating  capacity 
of  the  cerebral  centres  is  distinctly  related  to  the  integrity  of  the  vast 
network  of  sensory  nerves  distributed  upon  the  cutaneous  surface. 
The  striking  changes  produced  in  the  psychical  and  intellectual  in- 
dividuality of  persons  afflicted  with  deafness  or  blindness  may  be 
explained  upon  the  supposition  that  in  these  individuals  sensory  im- 
pressions are  received  and  felt  differently,  and  consequently  do  not 
produce  normal  and  active  object  pictures  upon  the  brain,  by  reason 


NEURASTHENIA.  441 

of  the  lowered  activity  of  the  organs  involved.  May  not  a  similar 
effect  be  produced  by  lowering  the  activity  of  that  great  organ,  the 
cutaneous  network  of  sensory  nerves?  The  effect  of  the  wet  pack 
upon  the  cutaneous  nerves  is  aided  by  the  diminution  of  blood  in  the 
cerebral  vessels,  which  it  has  been  shown  by  positive  experiments  to 
produce.  Thus  a  double  sleep-inducing  influence  is  set  in  motion  by 
the  wet  pack.  Sleep  is  ordinarily  the  result  of  a  primary  exhaustion 
or  fatigue  of  the  cerebral  centres ;  it  is  favored  by  the  removal  or  dimi- 
nution of  the  capacity  of  the  latter  for  receiving  exciting  impressions. 
The  relaxation  which  so  often  induces  sleep  in  persons  subjected  to  the 
wet  pack  is  also  produced  mainly  by  an  inhibition  of  this  receptivity 
to  exciting  impressions,  aided  by  diminution  of  the  supply  of  blood  and 
nutritive  material  to  the  cerebral  ganglia. 

The  demonstrated  calming  effect  of  the  wet  pack  not  only  renders 
it  a  valuable  agent  for  producing  sleep,  but  it  may  also  be  utilized  for 
the  purpose  of  restoring  the  lost  general  nerve  equilibrium  and  for  the 
enhancement  of  the  general  nutrition  (see  Rationale,  page  130).  When 
the  wet  pack  is  followed  by  douches  as  above  described,  this  double 
effect  may  be  evoked  with  certainty,  if  the  procedure  be  properly 
adapted  to  the  case. 

It  may,  however,  become  necessary  to  add  other  measures  to  "  ring 
the  changes"  in  our  therapeutic  activity.  The  most  important  element 
of  treatment  is  judicious  individualization  and  the  avoidance  of  routine. 

In  addition  to  the  above-detailed  procedures,  I  have  found  in  the 
treatment  of  insomnia,  that  opprobrium  medicorum,  which  taxes  our 
resources  to  the  utmost,  hip  baths  of  short  duration,  two  to  four  min- 
utes at  80°,  reduced  each  night  two  degrees,  until  50°  is  reached,  very 
useful.  They  render  the  brain  hyperaemic,  but  this  effect  is  followed 
after  removal  from  the  bath  by  reaction  on  the  abdominal  circulation, 
which  fills  this  large  vascular  area  and  thus  removes  cerebral  hyperaemia. 
The  duration  and  temperature  of  this  hip  bath  must  be  carefully 
watched  by  a  trained  attendant;  or,  better  still,  by  the  physician,  if 
the  best  result  is  to  be  obtained.  It  is  intended  to  increase  the  pelvic 
blood  flow  and  to  be  followed  by  a  calming  effect  upon  the  general 
condition. 

Warm  full  baths  can  be  made  useful  only  if  the  bed  is  warmed 
for  the  reception  of  the  patient,  and  he  is  very  rapidly  dried  and 
placed  in  it.  Exposure  to  the  air  of  the  bedroom,  which  usually 
is  70°  or  less,  after  a  full  bath  of  100°,  brings  on  a  reaction  which 
counteracts  the  effect  of  the  warm  bath.  The  latter  contracts  the 
cerebral  vessels;  the  former  dilates  them  again.  This  is  the  reason 
why  the  warm  full  bath  so  often  fails  in  insomnia.  A  much  better 
procedure,  based  on  Schuller's  experiments,  is  the  Neptune  girdle  at 
65°,  carefully  covered  with  flannel  (page  146).  This  produces,  first, 


442        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

hyperaemia  of  the  cerebral  vessels,  which  is  quickly  followed  by  anaemia, 
when  the  skin  under  the  pack  begins  to  warm  up,  and  its  vessels 
dilate.  Wet  compresses  around  the  legs  have  also  been  recommended 
for  this  purpose,  and  the  old  hydropaths  recommend  the  wearing  of 
woollen  socks  wrung  out  of  cold  water  and  covered  with  dry  woollen 
socks.  This  is  a  method  much  used  in  the  Zimmerman  Naturheil- 
anstalt  at  Chemnitz  in  Saxony. 

The  author  does  not  wish  to  be  understood  that  the  procedures 
mentioned  in  this  chapter  are  the  only  methods  to  be  recommended. 
They  simply  represent  an  outline  of  his  method,  from  which  he  devi- 
ates readily,  and  often  with  satisfactory  results  when  indicated. 

In  dealing  hydrotherapeutically  with  neurasthenia  or  with  other 
diseases,  the  chief  demand  made  upon  the  medical  attendant  is  famil- 
iarity with  the  technique  and  rationale  of  the  most  useful  procedures. 
If  he  takes  into  careful  consideration  the  therapeutic  indications  of 
each  case,  whether  he  aims  for  stimulation  or  calming  effects,  for  alter- 
ative, reducing,  or  perturbating  results,  he  may  adapt  the  procedure 
to  every  case.  He  must  individualize  more  cautiously  in  neurasthenia 
than  in  any  other  disease,  because  these  patients  are  easily  discouraged. 
I  have  not  infrequently  observed  otherwise  intelligent  patients  refuse 
to  continue  after  the  first  treatment,  although  this  is  always  mild.  I 
have  less  difficulty  in  persuading  my  own  patients  to  continue,  than 
the  patients  of  colleagues,  who  are  sometimes  influenced  by  the  graphic 
description  of  the  shock  (?)  endured  (from  water  at  95°),  or  from  the 
tremendous  (?)  force  of  the  stream  (ten  pounds  pressure),  or  from  the 
terrible  (?)  chills  experienced,  or  the  cold  contracted  after  this  heroic 
(?)  treatment — a  treatment  which  hundreds  of  the  feeblest  nervous 
women  have  endured  without  complaint. 

Such  cases  are  favorable  subjects  for  hydrotherapy,  if  they  can 
be  induced  to  persevere,  and  I  desire  to  warn  against  accepting  their 
statements.  The  value  of  the  mental  discipline  arising  from  thus 
overcoming  their  objections  and  groundless  fears  will  be  evident  to 
the  practised  therapeutist. 

That  injustice  will  not  be  done  the  patient  by  disregarding  his 
objections  is  evident  from  my  observations.  Among  one  hundred 
thousand  treatments,  of  which  I  have  reports  and  knowledge,  the  com- 
plainants do  not  number  fifty.  Among  these  about  a  dozen  have 
contracted  colds  on  the  day  of  treatment — an  infinitesimal  number 
even  if  their  accounts  be  always  correct,  which  is  doubtful.  Reaction 
is  usually  so  well  provided  for  that  the  injunction  to  go  into  the  open 
air  after  hydriatic  treatment  may  be  obeyed  without  hesitation  or 
apprehension  of  colds. 

Clinical  Histories. — The  following  clinical  histories  are   selected 


NEURASTHENIA.  443 

from  a  large  number,  to  illustrate  the  treatment  (domestic  and  institu- 
tional) of  neurasthenia,  which  may  serve  as  a  guide  to  the  practitioner  • 

I.  Neurasthenia  Gastrica — Home  Treatment. — Miss  W ,  daughter  of  an 

Ohio  physician,  aged  23  years,  was  referred  by  Dr.  Francke  H.  Bosworth,  the 
well-known  rhinologist.     Pale,  emaciated,  despondent,  the  picture  of  woe  and 
despair,  she  was  brought  into  my  office  by  her  sister.     She  had  been  ill  three 
years ;  suffering  first  from  fainting-fits  at  the  menstrual  period,  afterward  from 
violent  pains  in  the  right  hand,  traversing  the  body  and  concentrating  in  the 
epigastrium.     For  these  her  father,  a  physician,  had  been  compelled  to  adminis- 
ter morphine  for  a  month.     Her  stomach  became  irritable,  and  had  continued  so 
up  to  the  present  time  ;  she  vomited  and  spat  up  nearly  all  her  food,  mostly  the 
solids.     Sea  baths  did  not  improve  her.     She  studied  hard  and  grew  worse.     She 
lived  on  milk  and  farinaceous  mush,  and  her  stomach  was  regularly  irrigated, 
witnout  improvement. 

She  grew  worse,  became  emaciated  ;  she  took  peptonized  milk  for  a  month, 
but  vomited  it ;  meat  produced  the  same  effect.  She  now  lived  on  grapes,  which 
agreed  with  her ;  had  tonics,  pepsin,  and  all  possible  medication  which  her  father 
and  brother  could  muster,  without  avail.  She  was  sent  to  Dr.  Bosworth,  who  is 
a  friend  of  her  brother.  After  she  had  been  in  the  city  for  three  weeks  without 
improvement,  the  doctor  sent  her  to  me.  She  now  vomited  every  day ;  she  traced 
her  ailments  to  painting-lessons,  but  I  drew  from  her  the  history  of  a  potent 
psychical  factor  as  a  cause,  in  the  sudden  violent  insanity  of  the  favored  nurse  of 
her  childhood  which  occurred  just  previous  to  her  attack.  The  stomach  was 
washed  out  twice  a  week  to  remove  mucus  and  fermenting  material,  which  were 
not  abundant  and  ceased  after  a  few  irrigations.  She  received  general  faradiza- 
tion daily  and  every  morning  she  was  treated  with  the  dripping-sheet  at  60°  F., 
while  standing  in  warm  water,  with  three  affusions  of  50°  upon  the  sheet,  after 
which  she  was  well  dried  and  sent  into  the  open  air.  Under  this  systematic  man- 
agement she  improved  slowly  ;  vomiting  ceased  entirely  ;  she  went  to  the  seaside 
greatly  improved.  On  her  homeward  journey  she  called  to  tell  me  that  she  had 
grown  stout  and  felt  perfectly  well.  Two  years  later  she  wrote  me  that  despite 
reverses,  which  necessitated  her  adopting  teaching  as  a  means  of  livelihood,  her 
health  had  remained  perfect,  and  that  I  would  scarcely  recognize  her  as  the  same 
person. 

II.  NeurastTienia,  Agoraphobia,  and  Insomnia. — Mrs. ,  aged  30  years, 

was  referred  to  me  April  16th,  1895,  by  Dr.  A.  A.  Smith,  as  an  obstinate  case  of 
neurasthenia,  with  gastric  complication. 

After  returning  from  a  long  walk  in  1887,  she  was  suddenly  taken  with  a  curi- 
ous attack.  According  to  her  own  written  history,  which  is  here  abbreviated,  her 
vision  became  dim  and  hearing  far  away  ;  the  tongue  got  very  thick,  and  the  heart 
palpitated  tremendously.  She  thought  she  was  dying.  She  had  never  been  sick 
in  her  life  before.  She  was  put  to  bed  for  two  weeks.  These  attacks  continued. 
She  consulted  for  a  throat  trouble  Dr.  R.  P.  Lincoln,  who  treated  her  for  a  long 
time.  She  then  sought  advice  from  Dr.  A.  A.  Smith,  on  account  of  severe  in- 
digestion. 

Dr.  Smith  washed  her  stomach ;  he  found  no  food,  some  mucus,  very  little 
foam,  the  mucus  being  perfectly  white  and  clear.  She  improved  after  lavage 
and  other  treatment,  but  the  nervous  attacks  did  not  wholly  leave  her.  She  had 
a  dread  of  being  alone  in  the  street  or  in  the  house,  and  a  great  deal  of  palpita- 
tion. She  could  not  go  into  a  theatre,  church,  or  anywhere  else,  "  without  going 
to  pieces, "  and  did  not  go  out  into  the  street  without  an  attendant  for  several 


444       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

years.  Finally,  Dr.  Smith  sent  her  abroad ;  she  travelled  for  six  months ;  she 
went  to  Schwalbach,  took  the  iron  baths,  and  drank  the  water  for  almost  four 
weeks.  She  improved  wonderfully  for  a  time.  Her  appetite  was  good,  and  she 
slept  well  and  gained  considerable  flesh,  and  felt  almost  as  well  as  ever,  when 
suddenly,  while  in  her  seventeenth  bath,  she  was  seized  with  another  of  the 
attacks ;  these  continued  to  recur  during  the  rest  of  her  stay  in  Europe.  She 
lost  flesh,  sleep,  and  appetite. 

On  her  return  to  New  York  she  again  received  lavage  from  Dr.  Smith,  with 
the  same  satisfactory  result  as  before.  During  all  these  years  she  had  suffered 
intensely  from  insomnia ;  she  was  obliged  to  take  narcotics  more  or  less,  and 
always  was  oppressed  by  the  intense  fear  that  she  had  heart  trouble  ;  her  heart 
and  stomach  seemed  to  be  the  only  two  organs  that  were  very  uncomfortable. 
She  had  severe  pain  on  the  top  of  her  head  and  the  back  of  her  neck  almost 
incessantly ;  she  felt  as  though  a  weight  was  dragging  her  down.  She  never 
had  any  uterine  trouble,  and  had  never  suffered  during  her  menstrual  periods. 

She  now  tried  the  Zander  mechanico-therapeutic  treatment  for  two  months ; 
felt  much  broken  up  from  its  effects  at  first,  but  thought  she  was  somewhat  im- 
proved. 

She  was  not  seriously  afflicted  again  until  this  winter,  when  she  had  the 
grippe,  which  brought  back  the  old  attacks,  making  her  most  unhappy,  per- 
fectly helpless,  and  useless. 

Present  Condition. — Patient  presents  the  symptoms  described  above.  She  is 
spare,  tall,  brunette  ;  all  organs  normal ;  no  objective  symptoms  except  restive- 
ness  alternating  with  enforced  calmness,  and  a  pessimism  which  seemed  war- 
ranted by  her  past  experience.  She  complains  of  insomnia,  loss  of  appetite, 
agoraphobia ;  no  introspection. 

Treatment  was  begun  April  18th,  1895,  by  testing  her  reaction.  She  received 
the  usual  preparatory  treatment — a  hot-air  bath  until  warm,  followed  by  a  cir- 
cular douche  of  twenty  pounds'  pressure  for  one  minute,  95°  reduced  to  90°,  and 
a  fan  douche,  same  pressure,  reduced  to  85°,  for  half  a  minute ;  good  friction 
after  drying  and  Swedish  movements  of  extremities,  with  stroking-massage  of 
trunk  ten  minutes.  This  was  continued  for  four  days,  when  the  pressure  of  the 
douches  was  increased  five  pounds ;  the  fan  douche  was  given  at  85°  and  re- 
duced one  degree  each  day  for  five  days.  Menstruation  now  ensued.  On  the 
fifth  of  May  treatment  was  resumed.  The  hot-air  bath  and  circular  douche  re- 
mained as  at  first ;  the  fan  douche  was  given  for  85°  to  78°  for  half  a  minute  and 
thereafter  at  78°,  reduced  daily  one  degree. 

May  10th.  One  jet  douche  to  three  fan  douches  were  alternately  given  for  one 
minute  at  73°.  Reaction  being  good  and  patient  improving,  the  douches  were 
now  given  at  thirty  pounds  pressure. 

May  20th.  Patient  being  too  nervous  to  come  to  the  Institute,  she  received  at 
home  a  dry  pack  for  fifteen  minutes,  followed  by  ablution  at  65°  and  general  mas- 
sage, ten  minutes.  Continued  for  three  days. 

May  27th.  There  being  no  improvement  in  her  condition,  the  hip  bath,  six 
minutes  at  85°,  was  substituted,  followed  by  the  fan  douche,  twenty  seconds  at 
60°  F.  She  became  hysterical  after  the  treatment.  Being  now  afraid  of  the  hot- 
air  cabinet,  patient  received  a  dry  pack  until  warm,  followed  by  circular  douche 
at  90°  and  fan  douche  at  65°  for  one  minute.  (The  dry  pack  is  a  good  sub- 
stitute for  the  hot-air  cabinet,  for  home  treatment  or  for  timid  patients.) 

May  29th.  Patient's  condition  became  worse ;  she  complained  very  much  of 
"pain  in  ovaries  and  head."  She  was  depressed. 

June  30th.     This  treatment  had  been  continued,  the  Scotch  douche  to  upper 


NEURASTHENIA.  445 

spine  and  epigastrium  being  added  and  the  fan  douche  reduced  to  50°  as  a  stim- 
ulant. She  was  now  entirely  restored  and  went  into  the  country. 

May  4th,  1896.  Patient  returned  for  the  purpose  of  fortifying  herself  for  the 
approaching  summer ;  expressed  herself  as  feeling  fairly  well ;  no  feeling  of  ap- 
prehension ;  sleep  sometimes  unsatisfactory.  She  was  again  subjected  to  pre- 
paratory treatment,  with  Scotch  douche  to  abdomen,  which  she  regarded  as  the 
most  valuable  element  of  treatment,  affording  relief  of  distention. 

May  31st.  Complaining  still  of  occasional  insomnia,  the  wet  pack,  forty 
minutes  at  69°  followed  by  a  one-minute  circular  douche,  95°  to  90°,  and  fan 
douche,  one  minute  at  69°,  was  ordered,  to  alternate  every  other  day  with  the  hot- 
air  bath  and  the  same  douches. 

June  29th.  Under  this  treatment  she  has  steadily  improved,  and  was  dis- 
charged cured  to-day. 

Patient  has  remained  well  for  two  years. 

III.  Neurasthenia  Psychopathica. — Mrs. ,  aged  40  years,  from  San  Fran- 
cisco, has  four  children ;  perfectly  well  for  eighteen  years.  Since  birth  of  last  child, 
seven  years  ago,  has  been  ill ;  at  that  time,  her  husband  being  very  sick, 
great  demands  were  made  upon  her.  Went  to  the  World's  Fair  in  1893  in  charge 
of  a  party,  but  found  herself  suddenly  incapable  of  continuing  and  was  com- 
pelled to  return  home.  During  the  next  three  years  she  spent  most  of  the  time 
away  from  home  on  account  of  "  distressing  nervousness. "  She  now  went  to 
Japan  on  account  of  her  husband's  health.  She  "  could  not  account  for  her  great 
depression  during  the  sojourn  in  this  interesting  country,  and  constantly  trembled 
at  the  thought  of  resuming  her  r61e  in  life,  because  she  had  misgivings  as  to  her 
ability.  "  On  her  return  in  October,  1895,  to  use  her  own  language  :  "  I  was  care- 
less, forgetful,  indifferent  to  everything,  and  excitable,  restless,  and  fickle- 
minded  to  a  distressing  degree.  My  ordinary  duties  became  a  burden,  a  de- 
cision on  any  point,  however  trivial,  was  an  impossibility.  "  She  took  a  partial 
rest  cure  at  home,  but  found  it  necessary  to  go  to  a  private  sanatorium.  She  was 
nervous,  distressed,  dissatisfied  without  cause,  felt  she  was  no  use  to  any  one,  a 
detriment  to  those  nearest  and  dearest  to  her,  and  she  was  therefore  willing  to 
live  apart  from  them.  She  "  remained  away  a  whole  year  without  feeling  ma- 
ternal ambition,  lost  interest  in  everything.  She  had  massage,  steam  and  shower- 
baths  triweekly ;  she  lived  and  dragged  herself  wretchedly,  feeling  that  she  had 
sacrificed  her  position  in  the  home.  " 

On  her  return  home  she  suffered  unspeakably ;  was  now,  as  she  had  always 
been  since  her  illness,  subject  to  insomnia.  She  again  felt  impelled  to  leave 
home,  and  went  to  relatives.  Her  uterus  was  now  curetted.  She  felt  better 
until  she  got  up  ;  then  "  doubts,  fears,  questions  as  to  the  best  course  to  pursue,  " 
returned;  she  "felt  that  she  had  lost  her  grip. "  Her  hearing,  being  much  im- 
paired, added  to  her  mental  distress.  She  now  came  to  New  York. 

October  5th,  1897.  Mrs.  D.  presented  herself  in  order  to  try  systematic  hydro- 
therapy  as  a  last  resort.  She  stated  that  her  "  life  during  the  past  year  had  been 
spent  in  idleness,  dreading  the  coming  of  sunshine  in  the  morning  and  of  dark- 
ness at  night ;  the  thought  of  her  husband  and  children  deserted  was  madden- 
ing ;  sorrow  had  taken  the  place  of  peace,  irresolution  was  her  bane.  "  She  pre- 
sented no  organic  disease ;  weight,  stripped,  one  hundred  and  seven  pounds ; 
nutrition  much  below  par,  appetite  poor,  sleep  imperfect.  Ordered  careful 
regulation  of  diet,  exercise,  rest,  and  a  gradually  developed  hydriatic  treatment, 
patient  being  placed  in  charge  of  a  nurse. 

October  7th.     A  preparatory  douche,  95°  to  85°,  produced  a  hysterical  attack. 

October  20th.     Becoming  gradually  accustomed  to  the  treatment,  she  took  to- 


446       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

day  a  circular  douche,  95°  to  90°,  of  one  minute,  followed  by  Charcot  (fan) 
douche,  78°,  for  ten  seconds.  Her  weight  has  increased  three  pounds. 

Mental  condition  unsatisfactory.     Nurse  is  suspicious  of  suicidal  intent. 

October  22d.  Lost  one  pound  in  weight  and  is  much  distressed  by  the  fact. 
Ordered  hip  bath,  85°,  for  five  minutes,  followed  by  fan  douche  to  back,  78°,  ten 
seconds,  to  be  reduced  daily  one  degree. 

November  13th.  Took  the  same  hip  bath  followed  by  fan  douche,  74°,  for 
ten  seconds.  Has  gained  four  pounds,  but  expresses  no  satisfaction  over  gain.  Is 
extremely  despondent,  sighing,  and  irresolute. 

November  28th.  Hip  bath,  85°,  for  eight  minutes,  followed  by  jet  douche  to 
back,  65°,  for  fifteen  seconds,  and  fan  douche,  70°,  for  ten  seconds.  Has  lost  two 
pounds ;  greatly  dejected  by  this  loss. 

December  5th.  Treatment  continued  with  daily  reduction  of  douche  temper- 
ature and  increase  of  duration.  To-day  she  took  a  jet  douche  to  back,  58°,  for 
twenty -two  seconds,  and  general  fan  douche,  65°,  for  ten  seconds.  Weight  in- 
creased three  pounds  without  remark  by  patient. 

December  12th.  Weight  increased  two  pounds,  total  increase  being  eight 
pounds.  Mental  condition  better ;  patient  "  sees  some  ray  of  hope. " 

The  hip  bath  was  now  ordered,  alternated  with  a  perspiration  bath  to  stimu- 
late tissue  change.  The  urine  had  become  scant,  with  an  increase  of  urates  and 
phosphates. 

January  1st,  1898.  Under  this  treatment  she  did  not  improve.  She  was  sad- 
dened over  a  loss  of  three  pounds. 

January  25th.  She  has  continued  regular  treatment.  Took  to-day  hip 
bath,  85°,  for  seven  minutes,  followed  by  jet  douche.  Her  weight  is  one 
hundred  and  thirteen  and  one-half  pounds,  a  gain  of  six  and  one-half  pounds. 
Her  complexion  is  good ;  appearance  bright ;  mental  condition  decidedly 
improved.  There  was  a  lingering  degree  of  dissatisfaction,  but  I  deemed  it 
advisable  to  send  her  home  with  the  injunction  to  her  husband  to  insist  upon 
occupation. 

June  8th.  Frequent  reports  have  reached  me  stating  that  Mrs.  D.  is  a 
changed  being ;  she  is  cheerful,  active,  and  "the  life  of  the  house." 

This  satisfactory  result  is  in  my  opinion  due  chiefly  to  the  effect  of  a  judi- 
cious hydrotherapy  upon  the  nutrition  of  the  central  nervous  system.  Sugges- 
tion had  no  place  in  this  result ;  she  attributes  no  effect  to  my  treatment,  even 
now. 

Conclusion. — The  author's  observation  leads  to  the  conclusion  that, 
while  many  cases  of  neurasthenia  may  be  effectively  treated  without 
•water,  mild  cases  will  be  hastened  to  a  favorable  termination  by  add- 
ing water  to  the  therapeutic  measures  applied.  Those  who  cannot 
obtain  skilful  treatment  by  water  at  their  homes  will  do  better  without 
it  altogether,  unless  the  physician  teaches  some  member  of  the  family 
the  more  simple  procedures.  In  no  other  disease  is  hydrotherapy 
a  two-edged  sword  to  the  same  extent  as  in  neurasthenia. 

Whenever  institution  treatment  can  be  had  it  is  preferable,  because 
it  may  be  more  skilfully  and  judiciously  applied,  as  Dr.  Draper  has 
shown.  An  additional  and  very  great  advantage  of  institution  treat- 
ment lies  in  the  fact  that  it  requires  the  patient  to  withdraw  from  his 
or  her  unfavorable  environment  for  several  hours,  days,  or  months. 


NEURASTHENIA.  ,       447 

Many  cases  which  have  resisted  treatment  may  thus  be  carried  to  a 
favorable  issue,  even  if  they  devote  only  a  part  of  the  day  to  the  treat- 
ment. 

NEUBALGIA. 

Pain  in  the  course  of  a  nerve  has  received  the  appellation  neuralgia 
whenever  the  distressing  manifestation  is  not  .due  to  actual  disease  of 
the  nerve  or  of  some  organ. 

The  experienced  observer  has  frequent  occasion  to  realize  the  cor- 
rectness of  Komberg's  saying,  that  "  pain  is  the  prayer  of  the  nerve  for 
better  blood."  In  a  large  proportion  of  cases  of  neuralgia  the  pain 
is  but  the  expression  of  some  pernicious  influence  exerted  upon  the 
blood  by  malaria,  gout,  or  other  toxic  agent.  Moreover,  there  exists 
in  many  cases  of  neuralgia  a  distinct  anaemia.  Hyponutrition  is  also 
not  infrequently  marked,  either  as  the  cause  or  the  result  of  long- 
continued  nerve  pains. 

Next  to  ascertaining  and  removing  the  causes  of  neuralgia,  our 
therapeutic  measures  must  be  directed  to  the  building  up  of  the  failing 
nutrition.  These  objects  may  be  most  effectively  accomplished  by  rest 
of  the  affected  part  in  the  acute  stage,  and  by  alternating  rest  and  ex- 
ercise in  the  chronic.  Hydrotherapeutic  measures,  judiciously  adapted 
to  each  individual  case  when  the  patient  is  anaemic,  enhance  the  efficacy 
of  other  treatment,  and  often  suffice  alone.  The  methods  detailed 
above  for  improving  hsematosis  are  useful. 

It  is  essential  so  to  manage  all  hydriatic  treatment  in  this  affection 
that  good  reaction  ensues.  By  this  means  active  fluxion  through 
the  diseased  as  well  as  the  healthy  parts  is  determined.  Not  only  are 
metabolism  enhanced  and  noxious  products  eliminated  by  the  increase 
of  renal  and  cutaneous  activity,  but  the  increased  alkalinity  of  the 
Wood  tends  to  neutralize  any  acid  toxic  products  circulating  in  it  and 
endangering  the  integrity  or  otherwise  interfering  with  the  normal 
condition  of  the  nerve  trunks  and  their  branches.  The  general  nutri- 
tion is  always  enhanced  by  increasing  tissue  change,  improving  the 
quality  of  the  blood,  and  restoring  the  normal  resisting-capacity  of 
the  patient  to  atmospheric  changes. 

In  gouty  conditions,  the  wet  pack,  followed  by  half -baths  or  the  hot- 
air  bath  until  perspiration  is  free,  as  far  as  the  condition  of  the  patient 
warrants,  and  by  a  circular  douche  of  100°,  reduced  gradually  during 
one  minute  to  90°,  and  this  by  a  fan  douche  for  ten  to  thirty  seconds 
at  85°,  daily  reduced  one  degree,  has  given  me  the  best  results.  The 
local  pains  are  relieved  in  the  majority  of  cases  by  hot  fomentations 
applied  as  detailed  in  page  159,  until  free  perspiration  over  the  entire 


448       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

body  ensues,  followed  by  the  circular  douche  at  90°  for  one  minute, 
and  then  by  the  Scotch  douche  (alternation  of  110°  and  70°)  for  one 
minute  over  the  affected  nerve,  if  accessible.  This,  in  turn,  may  be 
followed  with  advantage  with  a  general  fan  douche  at  85°,  daily  re- 
duced until  70°  are  reached.  The  steam  Scotch  douche  is  more 
effective.  Occasionally  the  local  application  of  ice  bags  to  the  sciatic 
or  other  accessible  nerve  is  required. 

Mr.  R ,  referred  to  me  in  1895  by  Dr.  Hayd,  of  Buffalo,  had  been  under 

treatment  for  several  months.  His  sciatic  nerve  had  been  stretched  by  Dr.  Ros- 
well  Park  ;  he  had  been  pronounced  incurable  by  eminent  counsel  in  Philadel- 
phia. This  case  demonstrated  the  value  of  the  course  of  hydrotherapy  outlined 
above,  the  patient  being  restored  to  perfect  health  and  so  accustomed  to  cold 
water  that  he  has  taken  a  daily  plunge  at  all  seasons  with  marked  benefit  to  his 
general  health. 

A  number  of  trifacial  and  brachial  neuralgias  and  sciatica  have 
been  carried  to  a  satisfactory  issue  after  failure  of  prolonged  medica- 
tion, some  after  an  unsuccessful  rest  cure,  in  the  hands  of  the  author 
and  of  colleagues  of  the  highest  attainments.  Many  failures  have  also 
been  recorded  by  the  writer,  whose  misfortune  it  has  been  to  have 
mostly  desperate  cases  referred  to  him  for  hydrotherapy. 

I  have  found  sciatica  the  most  amenable,  and  brachial  and  trigemi- 
nal  neuralgia  the  most  rebellious  to  hydrotherapy. 

In  the  earlier  stages  the  dry  pack  and  hot  fomentation,  described  on 
page  413,  afford  the  most  marvellous  results,  if  followed  by  gradually 
reduced  douches  (95°-75°)  or  affusions  of  the  same  temperatures.  In 
the  more  chronic  cases  of  sciatica  and  other  neuralgias,  the  same  treat- 
ment is  useful;  but  a  difference  in  the  after-treatment  is  required. 
One  or  more  hours'  rest  in  the  dry  pack,  while  actively  perspiring,  not 
only  gives  rest  to  the  diseased  parts,  but  stimulates  tissue  change  and 
consequent  elimination  of  toxic  products.  Such  treatment  may  be 
given  at  the  patient's  home  with  great  advantage.  It  has  succeeded 
in  my  hands  after  the  salicylates,  quinine,  salol,  the  Paquelin  cautery, 
and  electricity  have  failed.  My  own  observation  is  confirmed  by  many 
contributions  to  the  subject. 

Professor  Winternitz  reports :  *  "In  the  institution  at  Kaltenleut- 
geben,  five  hundred  and  eighty -five  cases  of  neuralgia  have  been  re- 
ceived during  the  past  twenty-five  years.  Among  these  many  were 
symptomatic  of  other  general  diseases.  The  lancinating  pains  of  tabes, 
the  gastric  pains  of  dyspeptics,  and  cases  of  toxic  neuritis  are  not  in- 
cluded. Only  those  cases  are  included  in  which  the  characteristic 
pains,  involving  only  certain  nerve  trunks,  formed  the  entire  disease 
picture. 

"Among  the  cases  here  considered  we  find  hemicrania;  frontal, 
*  Blatter  fur  klinische  Hydrotherapie,  January,  1892. 


NEURALGIA.  449 

supraorbital,  infraorbital,  maxillary,  cilio-temporal,  and  occipital  neu- 
ralgias ;  also  neuralgic  affections  of  the  trunk  and  extremities  in  the 
course  of  most  of  the  sensory  nerves. 

"  Most  numerous  were  cases  of  intercostal,  cervical,  brachial  neu- 
ralgia, and  especially  sciatica;  also  many  cases  of  testicular  neuralgia 
and  coccygodynia. 

"  The  result  of  the  treatment  of  these  five  hundred  and  eighty -five 
cases,  mainly  by  means  of  physical  procedures,  thermic,  mechanical, 
and  electrical,  show  fifty -two  per  cent  of  recoveries.  Only  five  per 
cent  were  dismissed  without  being  benefited;  all  the  others  were  im- 
proved. 

"  These  figures  entitle  hydrotherapy  to  great  consideration  as  an 
antineuralgic  application.  They  do  not  cover  my  entire  experience 
with  neuralgia.  At  least  as  many  cases  were  treated  among  my  pri- 
vate clientele  and  at  the  poly  clinic. 

"  More  or  less  energetic  hydriatic  procedures  have  effected  cure  in 
the  most  obstinate  and  inveterate  cases. 

"I  have  seen  a  case  of  prosopalgia,  which  had  lasted  several 
months,  disappear  after  a  single  rain  bath  at  8°  R.  (50°  F.),  and  not 
recur  for  three  months,  the  length  of  time  the  patient  remained  under 
observation ;  we  cannot  often  expect  so  fortunate  a  result.  However,  it 
is  not  rare  to  see  the  pain  in  old  and  obstinate  neuralgias  stop  for  a 
greater  or  less  interval  or  become  much  milder  after  the  first  hydriatic 
procedures.  The  Scotch  douche  is  especially  recommended  in  this 
connection,  being  not  only  of  curative,  but  also  of  decided  prognostic 
value,  when  it  relieves  the  pain  early." 

Winternitz  was  the  first  to  demonstrate  the  value  of  alternations 
of  heat  and  cold  in  neuralgia.  He  claims  that "  heat  renders  the  nerves 
more  receptive  for  the  changing  innervation  and  revulsion  which  the 
succeeding  lower  temperature  produces. 

"  We  may,  with  advantage,  precede  our  applications  of  cold  by  di- 
rect heating  or  warm  compresses. 

"  To  summarize,  the  treatment  employed  was  as  follows :  Great  tem- 
perature contrast,  intense,  but  of  short  duration;  mechanical  influ- 
ences, as  thermal,  massage,  sweating,  resisting  movements,  energetic 
active  exercise  when  possible,  passive  motion  when  necessary,  friction, 
mechanical  manipulation,  electricity,  warm  drinks,  and  in  some  cases 
internal  medication.  The  intense  nervous  influence,  the  revulsion  and 
nerve  excitation,  the  powerful  primary  and  reflex  action  upon  the  cir- 
culation, the  production  of  active  fluxion  to  the  various  organs,  their 
influence  upon  secretion  and  excretion,  seem  to  be  the  factors  which 
have  cured  fifty-two  per  cent  of  my  cases  and  produced  marked  im- 
provement in  so  many  of  the  others." 
29 


450      THE  PRINCIPLES  AND  PRACTICE   OF  HYDROTHERAPY. 

Sciatica. — Dr.  Otto  Pospischl  furnishes  *  a  report  of  one  hundred 
and  thirty-five  more  or  less  desperate  cases  of  sciatica  treated  at  Kal- 
tenleutgeben  during  twenty-five  years,  of  which  only  six  per  cent  left 
without  being  cured,  fifty-seven  per  cent  were  completely  restored  to 
health,  and  thirty-seven  per  cent  were  decidedly  improved.  He  cites 
a  very  interesting  case  which  was  much  benefited  by  this  treatment, 
and  which  is  here  reproduced  in  abstract  as  an  illustration  of  correct 
hydrotherapy  in  a  desperate  case  and  as  a  guide  to  its  management. 

A ,  aged  24  years,  acquired  a  most  severe  and  painful  sciatica  in  the  left 

leg  by  sitting  on  cold  wet  stones.    The  spine  had  become  bent  to  the  right  and 


FIG.  73.— Sciatica.t 


(6) 


forward,  and  could  be  straightened  only  with  great  difficulty  and  pain.     He  was 
treated  assiduously  by  various  physicians  without  obtaining  relief.     He  then 

*  Blatter  fur  klinische  Hydrotherapie,  1891. 

fin  a  review  of  the  first  edition,  the  result  in  this  case  was  sceptically 
criticised.  A  recent  case  in  the  Hydrotherapeutic  Institute  of  Columbia  Uni- 
versity (Vanderbilt  Clinic)  presented  almost  the  same  picture,  which  indeed  is 
an  exaggeration  of  the  usual  position  assumed  by  the  patient  in  intense  sciaticas. 
The  result  of  treatment  was  the  same  as  in  this  case.  The  first  Scotch  steam 
douche  enabled  the  patient  to  walk  almost  erect  to  his  dressing-cabinet.  He  con- 
tinued to  improve  until  he  was  discharged  cured  in  four  weeks,  after  six  months' 
futile  effort  under  other  treatment.  Several  other  less  severe  cases  have  re- 
covered, after  failure  of  other  measures,  and  are  recorded  by  Drs.  Cleghorn  and 
Wittson,  under  direction  of  Dr.  Shrady,  Chief  of  the  Clinic. 


NEURALGIA.  451 

applied  for  hydriatic  treatment.  The  accompanying  picture  (a)  shows  the  pa- 
tient at  rest  one  week  after  beginning  treatment.  It  was  impossible  to  photo- 
graph him  at  first,  because  the  pain  was  so  intense  that  he  could  not  stand.  He 
was  compelled  to  take  morphine  every  night  for  four  weeks;  during  which  time 
he  had  thirty  baths,  one-quarter  to  one-half  hour  in  duration,  at  104°  F.,  and 
8  gm.  salicylic  acid  daily  without  much  effect.  The  sciatic  nerve  was  now 
stretched  under  chloroform  without  permanent  result.  His  reactive  capacity 
being  feeble,  treatment  was  begun  with  ablutions  at  63.5°  F.,  reduced  gradually 
to  52°,  in  order  to  prepare  the  skin  for  the  piece  de  resistance  of  sciatica  therapy — 
the  Scotch  douche.  But  his  reaction  remained  poor,  until  much  colder  water  was 
applied  with  considerable  friction  of  unaffected  parts  of  the  body.  These  cold 
•wet  rubbings  produced  a  refreshing  and  alleviating  effect,  which  gradually 
aided  the  task  of  weaning  him  from  morphine.  Now  the  Scotch  douche  was 
applied.  After  a  general  rain  bath  of  ten  seconds,  with  water  at  86°  F. ,  to  pre- 
pare the  skin  for  thorough  warming  up  by  steam,  the  latter  was  applied  at  about 
120°  over  the  entire  body,  but  especially  the  affected  part.  This  was  followed 
by  a  fan  douche  of  48°  for  three  to  four  seconds  over  the  entire  body,  especially 
the  affected  parts.  These  hot  and  cold  applications,  changed  three  to  five  times, 
effected  an  intense  cutaneous  hypersemia.  Now  the  patient  was  exposed  to  a  rain 
bath  of  48°  for  three  seconds,  rapidly  dried,  and  taken  out  into  the  bright  sun. 
This  thermic  massage  was  used  three  times  a  week,  and  on  alternate  days  he  was 
subjected  to  a  cold  fan  douche  for  fiften  seconds,  which  produced  almost  the  same 
reactive  effects  as  the  douche. 

An  intestinal  irrigation  of  one-half  litre  of  water  slightly  impregnated  with 
salt  at  77°  F.  was  daily  applied  for  six  weeks,  even  when  the  bowels  acted  regu- 
larly, to  insure  against  scybalse. 

An  important  part  of  the  treatment  was  the  trunk  compress  (Neptune  girdle) 
and  a  wet  compress,  well  covered  with  dry  flannel  over  the  affected  extremity. 
After  the  first  week  the  patient  was  so  much  better  that  he  could  take  half -baths 
at  77°-80°  for  three  or  four  minutes,  which  calmed  and  gave  him  sleep.  Two 
weeks  later  he  received  a  general  wet  pack  of  three-fourths  hour's  duration  prior 
to  this  half -bath. 

The  second  figure  (5)  shows  the  result  of  eight  weeks'  treatment.  The 
sciatica  was  cured  and  the  deformity  corrected,  patient  looked  robust,  and  a  pre- 
viously existing  tuberculous  consolidation  of  the  apex  of  the  right  lung  had  dis- 
appeared. 

Patient  continued  treatment  for  two  and  one-half  months,  showing  a  result 
from  judicious  hydrotherapy  which  could  not  be  obtained  by  any  other  treatment. 

Buxbaum*  reports  from  the  University  Poliklinik,  at  Vienna,  four 
unsuccessful  cases,  one  of  which  was  the  following: 

Ischias  scoliotica  in  a  man  38  years  of  age  ;  suffered  eight  months ;  his  body 
was  drawn  to  the  right  and  forward  ;  he  could  not  move  without  excruciating 
pain ;  had  received  routine  medication.  Patient  received  a  short  general  cold 
rain  bath  (temperature  not  given),  followed  by  directing  steam  at  122°  upon  the 
affected  part  for  one  minute.  This  was  succeeded  by  a  cold  fan  douche  upon  the 
extremities.  The  steam  douche  and  cold  fan  douche  were  thus  alternated  for 
five  or  six  minutes ;  treatment  being  concluded  by  a  short  cold  rain  bath.  No 
result  after  several  weeks  treatment. 

*  Blatter  fur  klinische  Hydrotherapie,  April,  1894. 


452        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

He  also  reports  the  following  successful  cases,  which  are  here  given 
in  brief  outline : 

CASK  II. ,  27  years  old,  has  been  suffering  from  sciatica  for  three  years,  having 
been  treated  by  all  kinds  of  liniments,  massage,  electricity,  sulphur,  etc.  He 
received  daily  the  Scotch  douche,  alternating  steam  and  cold  water,  which  gave 
him  some  relief  at  once.  In  fourteen  days  he  was  discharged  cured,  and  was 
well  two  months  later. 

CASE  HI. ,  84  years  old,  sciatica  six  months ;  constantly  under  treatment, 
which  included  Turkish  baths,  every  other  day  for  three  months.  After  Scotch 
douche  daily  for  eight  days  he  was  entirely  cured. 

CASE  IV.,  39  years  old,  locomotive  engineer ;  ill  six  years,  using  hypodermics 
of  morphine  and  all  other  routine  treatment.  He  could  attend  the  clinic  only 
every  third  day,  when  he  received  the  Scotch  douche.  A  cold  compress  over  the 
affected  limb,  to  be  worn  over  night  and  followed  in  the  morning  by  a  cold  ab- 
lution, was  ordered.  He  was  entirely  restored  in  three  weeks. 

Buxbaum  claims,  and  I  can  confirm  the  validity  of  this  claim,  that 
recent  sciaticas  may  often  be  removed  by  one  or  more  Scotch  douches ; 
and  that  hydrotherapy  belongs  to  the  most  precious  antineuralgic 
remedies. 

Borischpolosky*  reports  thirty-two  cases  of  sciatica  treated  by 
Scotch  douches,  of  which  twenty-three  were  cured  and  seven  improved. 
He  regards  this  effect  as  due  to  the  furtherance  of  the  nutritive  and 
tissue-change  conditions  in  the  diseased  nerves,  produced  by  the  ther- 
mic and  mechanical  action  of  the  douche. 

Dr.  Julius  Fodor  mentions,  in  his  report  for  1893  of  the  Hydrother- 
apeutic  Pavilion  of  the  Vienna  University  Poliklinik,  thirty  cases  of 
sciatica,  of  which  twenty-four  were  cured  and  six  improved. 

In  the  hydrotherapeutic  department  of  the  Charite  Hospital,  the 
author  has  observed  a  unique  method  of  treating  sciatica  that  deserves 
to  be  imitated,  inasmuch  as  the  claims  for  its  excellent  results  arise 
from  the  reliable  observations  of  Brieger,  Krebs,  Laqueur,f  who  treat 
large  numbers. 

The  patient  is  immersed  in  water  of  100°  to  104°,  contained  in  a 
very  large  tub.  He  is  made  to  move  the  affected  limb  slowly,  as  far 
as  endurance  would  admit,  and  in  every  direction  which  produces  pain. 
This  is  done  daily  for  half  an  hour  or  longer;  active  and  passive 
movements  are  also  made  by  an  assistant,  usually  a  physician,  who 
after  the  bath  administers  gentle  massage  around  the  sciatic  nerve  re- 
gion. Brieger|  also  commends  the  steam  douche,  alternated  with  cold 
douches  (40°  to  60°  F.),  the  former  one  to  three  minutes,  the  latter  ten 

*  Wratsch,  1896,  No.  17. 

fZeitschrift  fiir  physikaliscbe  und  diatetische  Therapie,  von  Ley  dan,  Gold- 
scheider  und  Jacob,  1902,  p.  48. 

\  Deutsche  med.  Wochenschr.,  March  12th,  1902. 


NEURALGIA.  453 

to  fifteen  seconds.  The  treatment  lasts  from  .several  weeks  to  three 
months.  Improvement  usually  ensues  early,  even  in  cases  previously 
treated  without  success  by  other  measures.  Of  twenty-four  cases  of 
neuralgia,  only  one  failed  (a  tuberculous  case). 

Later  statistics  of  Brieger's  method  are  furnished  by  Sommer.* 
Although  this  method  does  not  always  succeed,  it  is  credited  with 
80-90  per  cent  recoveries.  Sommer  very  properly  advises  judicious 
individualization.  Although  the  systematic  passive  movements  within 
the  warm  bath  are  very  useful,  massage  is  deprecated  in  the  early 
treatment  of  rheumatism.  After  improvement  has  been  inaugurated 
Sommer  advises  douche  treatment. 

Conclusion. — The  clinical  observations  of  Winternitz,  Buxbaum, 
Brieger,  and  others  are  here  reproduced  in  order  to  afford  the  reader 
an  insight  into  the  hydriatric  methods  of  various  practitioners  of  hy- 
drotherapy.  It  is  unfortunate  that  similar  observations  are  not  acces- 
sible in  the  records  of  our  own  hospitals  and  clinics.  This  arises  from 
the  circumstance  that  while  some  of  our  text-books  refer  to  douches, 
packs,  hot-air  baths,  in  a  cursory  and  indefinite  manner,  they  do  not 
offer  the  same  detailed  instructions  for  their  application  which  they 
devote  to  the  discussion  of  the  saiicylates,  electricity,  nerve  stretch- 
ing, blistering,  firing,  etc.  The  practitioner  who  has  not  had  special 
training  in  hydrotherapy  treats  the  latter  with  indifference,  and  allows 
his  patients  to  wander  into  the  hands  of  lay  and  medical  quacks  rather 
than  apply  a  treatment  which  has  been,  as  shown  above,  satisfactorily 
utilized. 

The  author  has  made,  in  the  hydriatic  treatment  of  sciatica,  pre- 
cisely the  same  observation  as  in  other  diseases.  Obsta  principiis 
should  be  the  motto  of  the  therapeutist  always.  This  principle  is 
more  essential  in  hydrotherapy  than  in  other  branches  of  therapeutics. 
The  most  brilliant  results  from  the  water  treatment  are  obtained  in 
recent  cases  of  sciatica,  which  are  usually  so  rebellious  to  medication. 
Very  few  of  these  fail  to  respond  to  the  daily  application  of  the  dry 
pack  with  hot  fomentations  to  the  affected  part,  and  subsequent  ablu- 
tions or  circular  and  fan  douche  at  80°-60°.  In  sciatica  of  long  stand- 
ing, the  beneficent  effect  of  this  treatment  may  be  disputed,  the  effect 
being  charged  to  the  time  element,  many  cases  recovering  sooner  or  later 
without  treatment.  But  even  in  these  cases  the  rapid  improvement 
following  upon  judiciously  adopted  hydrotherapy  in  many  desperate 
cases  is  so  striking  that  some  hydrotherapists  regard  it  as  a  rule  that, 
if  improvement  does  not  ensue  quickly  after  beginning  the  treatment, 
it  should  be  changed  or  abandoned  altogether.  In  other  forms  of  neural- 
gia the  same  results  are  obtainable  by  means  of  hydrotherapy  in  a  lesser 
degree,  but  still  to  a  far  greater  extent  than  by  medication  alone. 

*  Loc.  cit.,  1906,  No.  9. 


454       THE  PRINCIPLES  AND  PRACTICE  OF  HYDBOTHEBAPY. 


HYSTEBIA. 

Patients  suffering  from  this  hydra-headed  malady  have  always  been 
the  bane  of  doctors.  They  are  usually  peripatetic  individuals,  who 
travel  from  one  office  to  another  to  pour  their  lengthy  stories  of  woe 
into  the  doctor's  ear. 

The  aim  of  treatment  is  here,  as  it  is  in  neurasthenia,  to  restore 
the  lost  "  mental  equilibrium"  by  improving,  through  more  favorable 
environment,  diet,  rest  or  exercise,  and  hydrotherapy,  the  nutrition. 

What  has  been  said  in  the  chapter  on  "  Treatment  of  Neurasthe- 
nia" is  also  applicable  here.  Indeed,  while  these  two  functional  mala- 
dies differ  very  materially  in  most  respects,  their  treatment  is  closely 
allied. 

The  great  neurologist  Charcot  was  the  most  successful  neuro-thera- 
peutist  of  his  day,  because  he  not  only  commanded  the  highest  attaina- 
ble knowledge  of  nervous  diseases,  their  diagnosis  and  pathology,  but 
his  large  clinical  material  enabled  him  to  test  various  methods  of  treat- 
ment, many  of  which  have  become  permanent.  Among  them  stand 
easily  foremost  the  spinal  douche  and  other  hydrotherapeutic  measures, 
which  he  practised  with  marvellous  success.  Charcot  says :  *  "  Hydro- 
therapeutic  health  institutes  in  Paris  have  treated  such  patients  with 
complete  success  for  the  last  fifteen  years,  because  they  possess  admi- 
rable arrangements  for  this  purpose." 

Charcot' s  success  appears  to  have  given  rise  to  the  fallacious  idea 
that,  inasmuch  as  pouring  cold  water  upon  a  girl  writhing  under  a 
hysteric  spasm  or  lying  lifeless  in  a  hysteric  swoon,  often  restores  her, 
this  heroic  method  may  be  indiscriminately  applied  to  all  cases  of  hys- 
teria in  and  out  of  the  paroxysmal  stages.  Charcot' s  douches  are  often 
pictured  as  the  playing  of  streams  of  cold  water  from  a  hose  upon  the 
trembling  forms  of  these  sufferers. 

My  own  observation  of  the  action  of  these  spinal  douches  in  hysteria 
leads  to  the  conclusion  that  they  are  useful  in  many  forms  of  hysteria 
to  stimulate  the  nerve  centres  and  to  restore  the  disturbed  equilibrium. 
The  spinal  douche  is  effective  chiefly  because  it  may  be  applied  at  very 
low  temperature  without  depressing  effect.  This  is  due  to  the  fact 
that  only  a  small  portion  of  the  cutaneous  surface  is  attacked,  and,  this 
being  on  the  muscular  and  bony  back,  the  blood  is  not  driven  to  the 
interior  portions  of  the  body  thus  treated.  Moreover,  whenever  only  a 
portion  of  the  body  is  subjected  to  a  cold  procedure,  the  remainder  is 

*"  Clinical  Lectures  on  Certain  Nervous  Diseases,"  translated  byE.  P. 
Hurd  (G.  S.  Davis,  1888),  p.  181. 


HYSTERIA.  455 

left  unembarrassed  to  aid  in  revoking  reaction.  In  addition,  the  spine 
is  capable  of  accepting  douches  of  the  strongest  pressure. 

I  am  not  disposed  to  attribute  any  specific  effect  to  spinal  douches : 
there  is  no  evidence  to  prove  such  an  effect.  The  real  benefit  is  de- 
rived from  the  building  up  of  the  lost  nerve  tone,  the  improvement  of 
appetite,  digestion,  and  assimilation ;  and  especially  from  the  enhance- 
ment of  the  resisting-power  of  the  nerve  centres  by  transmission  of  the 
tonic  effects  from  the  peripheral  cutaneous  nerves,  which  receive  them 
from  the  impact  of  cold  or  cool  water  under  strong  pressure. 

As  has  been  shown  in  the  hydriatric  management  of  neurasthenia, 
•we  have  here  also,  with  regard  to  water  treatment,  two  types  of  hys- 
teria— the  excitable  and  the  depressed.  In  the  excitable  type  low  tem- 
peratures and  active  mechanical  procedures  should  be  avoided.  The 
wet  pack,  so  ably  discussed  by  Dr.  Mary  Putnam  Jacobi,  is  the  most  use- 
ful procedure.  The  patient  should  be  daily  enveloped  in  a  wet  pack,  the 
sheet  wrung  out  of  water  not  below  60°  nor  above  70°,  and  lie  in  it  with 
open  windows  for  an  hour  or  more,  doubling  the  sheet  if  the  procedure 
is  to  be  prolonged.  This  should  be  followed  by  a  half-bath  for  ten 
minutes  at  80°,  or  the  circular  douche  for  fifteen  seconds  at  85°,  under 
twenty  pounds'  pressure.  Once  or  twice  a  week  the  wet  pack  may  be 
followed  by  a  circular  douche  for  ten  seconds  at  lower  temperature  and 
higher  pressure — say,  90°,  reduced  quickly  to  75°,  under  twenty 
pounds'  pressure;  and  the  fan  douche,  five  seconds  at  85°  F.,  and  not 
lower  than  65°  F.,  same  pressure. 

The  wet  pack  must  be  followed  by  an  affusion  from  half  a  bucket 
of  water  at  85°-60°,  the  patient  sitting  in  an  empty  tub,  the  attendant 
standing  upon  a  chair. 

The  depressed  type  is  benefited  by  daily  cold  (80°,  daily  reduced 
two  degrees)  affusions  at  home,  while  standing  above  the  ankles  in 
warm  water.  The  hot-air  bath,  to  bring  the  cutaneous  vessels  into 
activity  and  fill  them  with  blood,  is  an  excellent  preliminary  meas- 
ure in  institutions,  where  it  may  be  followed  by  the  circular  douche 
under  twenty-five  pounds'  pressure  for  thirty  seconds  at  85°,  reduced 
gradually  to  70°  during  the  first  few  applications,  and  later  to  60°. 
This  may  be  followed  by  the  spray  douche  for  five  seconds  at  65°  F., 
and  later  by  the  jet  douche  for  three  seconds  at  65°  to  55°  F.  If 
the  lowest  (50°)  is  well  borne,  the  pressure  may  be  increased  two 
pounds  every  day  until  thirty  pounds  are  reached.  The  strong  jet 
douche  over  the  back  alone  is  perhaps  the  most  valuable  single  measure 
in  this  type,  provided  it  is  daily  lowered  in  temperature  and  increased 
in  pressure. 

In  domestic  practice  a  dry  pack  for  an  hour,  preceded  by  friction 
to  dilate  the  cutaneous  vessels,  and  continued  until  patient  feels  quite 


456       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

warm,  followed  by  a  rapid  affusion  as  above  described  but  of  much 
lower  temperature,  may  be  substituted  advantageously  for  the  hot-air 
bath  and  douche. 

Home  treatment  should  always  be  administered  before  sending  the 
invalid  away.  These  patients  should  not  be  hastily  dealt  with;  gen- 
tleness, combined  with  firmness,  will  bring  success  in  this,  as  it  does 
in  all  hydriatric  practice,  especially  if  the  physician  is  broad-minded 
and  does  not  trust  to  this  or  any  one  remedial  measure.  In  this,  as  in 
many  other  diseases,  the  addition  of  hydrotherapy  will  often  produce 
surprising  results.  Clinical  illustration  of  this  fact  abounds.  The 
following  are  cited  from  hospital  practice,  because  the  records  are 
more  reliable. 

The  annual  reports  of  the  house  physicians  of  the  Montefiore 
Home  usually  contain  brief  outline  histories  of  cases  of  hysteria  which 
had  been  treated  in  vain  for  years,  and,  being  regarded  as  incurable, 
were  on  that  account  admitted  to  the  home  and  were  here  treated  with 
hydrotherapy.  A  case  of  this  type  is  referred  to  by  Dr.  Ettinger 
(Keport  for  1890)  as  follows : 

"  A  young  girl  came  to  us  with  a  complete  palsy  of  the  left  arm  and  blind- 
ness of  the  left  eye,  of  functional  origin.  For  two  years  she  sought  relief  every- 
where without  avail.  She  was  then  referred  to  us  as  a  hopeless  case ;  but  it  has 
been  our  good  fortune  completely  to  restore  the  power  to  her  arm  and  vision  to 
her  eye,  and  to  remove  her  intense  depression  of  spirits.  She  is  now  supporting 
herself  as  a  domestic. 

"  This  is  the  type  of  a  number  of  similar  but  less  severe  cases  in 
which  we  have  been  equally  fortunate.  In  all  cases  hydrotherapy  has 
been  the  important  therapeutic  agent.  In  one  case  of  severe  hystero-epi- 
lepsy  in  a  man,  it  has  been  the  one  agent  to  which  improvement  is  due, 

"  J.  S ,  aged  58  years ;  Dutch ;  negative  family  history  ;  gives  history  oi 

convulsive  seizures  of  twenty -five  years'  duration,  often  from  ten  to  fifteen  times 
a  day.  After  admission  he  had  from  one  to  three  seizures  daily.  Diagnosis, 
hystero-epilepsy.  Treatment,  Charcot  douche  daily  to  spinal  column,  resulted 
in  gradual  diminution  of  convulsive  attacks  to  complete  cessation  at  the  end  of 
three  months.  After  complete  freedom  for  another  three  months  he  was  dis- 
charged. " 

Dr.  Eosenthal  relates  (1891):  "The  use  of  water  as  a  therapeutic 
agent  in  Bright' s,  rheumatism,  and  various  diseases  of  the  nervous 
system  has  maintained  its  past  record. 

"  T.  R ,  cataleptic  hysteria,  has  been  discharged  as  cured  and  has  been 

engaged  for  months  in  the  service  of  a  prominent  house  of  this  city,  without  any 
recurrence  of  her  disease. 

"T.  H .representing  another  and  severe  type  of  hysteria,  with  partial 

palsy  of  right  arm  and  complete  of  the  fingers,  with  severe  contracture  of  the 


HYSTERIA.  457 

fingers,  with  signs  of  organic  changes  in  the  fingers  and  wrist,  is  now  gradually 
recovering  from  those  conditions.  For  four  years  she  had  been  treated  by  some 
•af  tho  most  eminent  men  outside  of  our  institution  with  no  apparent  result.  " 

Dr.  C.  Bloch  reports  (1892) : 

"L.  H ,  subject  to  epileptoid  convulsions  and  choreic  attacks,  at  times 

combined  with  hallucinations,  aphasia,  and  complete  paralysis.  There  were 
'  hysterogenic  zones, '  the  touch  of  which  would  call  forth  one  of  those  spells. 
For  three  years  she  had  been  treated  by  many  prominent  specialists  and  been  in 
various  hospitals,  with  partly  no,  partly  passing,  improvement.  On  her  arrival 
she  had  the  described  attacks  as  frequently  as  six  to  ten  times  a  day.  After  five 
months'  treatment  in  the  Home  she  gradually  lost  all  symptoms  and  will  soon  be 
discharged  cured." 

Drs.  Bloch  and  Frankel  (1893)  relate:  "Of  the  several  cases  of 
grave  hysteria,  we  mention  but  one  combined  with  Meniere's  disease, 
who  for  seven  years  had  been  an  inmate  of  a  hospital.  The  patient 
was  confined  to  bed  and  suffered  terrible  agonies  for  years.  He  now 
walks  about  and  will  soon  be  entirely  cured." 

The  report  of  the  same  institution  for  1894,  made  by  Drs.  Bloch 
and  Frankel,  contains  the  following  brief  histories  : 

"  B.  M ,  22  years  old,  servant  girl,  after  a  fall  from  a  stepladder,  contracted 

the  following  series  of  symptoms :  Her  right  arm  and  the  muscles  of  back  and 
neck  and  tongue  and  jaws  were  paralyzed  and  in  the  state  of  rigor ;  on  trying  to 
walk  she  would  frequently  tumble  over  and  fall ;  sensibility  all  over  the  body 
nearly  lost.  She  is  now  well  and  will  shortly  be  discharged.  Previous  to  ad- 
mittance to  our  institution,  she  had  for  two  years  been  treated  by  many  physi- 
cians. 

aL.  R ,  55  years  old,  admitted  October,  1893,  stricken  with  paralysis  of 

all  four  extremities,  has  now  fully  recovered  his  health  and  will  shortly  be  dis- 
charged." 

The  following  brief  outline  of  a  case,  which  is  admirably  detailed 
in  all  its  scientific  aspects  by  Dr.  Bourneville  in  Progres  Medical  for 
August  26,  1882,  may  also  serve  as  a  clear  illustration  of  the  capabili- 
ties of  hydrotherapy  in  the  most  severe  types  of  hysteria : 

"  The  father  and  grandfather  of  the  patient  were  nervous  and  had  migraine ; 
the  mother  had  convulsions  and  torticollis  in  infancy ;  one  maternal  aunt  is  an 
idiot ;  brothers  and  sisters  died  of  convulsions ;  the  patient  had  convulsions  for 
nine  months.  An  attack  of  hystero-epilepsy,  which  is  admirably  portrayed,  oc- 
curred in  February,  1880 ;  then  sensorial  hemiansesthesia,  hysterogenic  zones, 
and  aura.  The  convulsive  attacks  and  contortions,  recurring  with  great  regu- 
larity, are  fully  described  ;  they  were  followed  by  laughing  and  delirium.  The 
treatment  had  consisted  of  tonics,  bromide  of  camphor,  baths,  and  gymnastic 
exercise.  Cold  douches,  rain  and  jet,  were  now  administered  from  thirty  to 
forty  seconds,  from  April  16th  to  May  3d ;  a  vigorous  hydrotherapy  was  next 
pursued,  once  a  day  until  the  end  of  the  year.  In  August  the  attacks  became 
more  rare  and  brief,  and  ceased  entirely  on  December  13th.  During  the  first 
three  months  of  1882  the  child  showed  great  irascibility,  and  was  subject  to  ner- 


458       THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

vous  laughter.  The  douches  were  resumed.  On  August  24th,  1882,  the  child's 
condition  was  good,  and  there  have  been  no  new  attacks.  "  (Cited  by  Duval. ) 

The  following  brief  history  from  my  private  case  records  may  be 
of  interest  as  a  guide  to  hydriatic  treatment : 

A.  F ,  aged  15  years,  was  brought  to  the  Hydriatric  Institute  July  19th, 

1892,  by  his  father,  who  said  that  on  the  31st  of  March,  1892,  on  the  day  of  his 
daughter's  burial,  the  boy  "fainted.  "  Ten  days  later  he  fainted  in  school,  and 
again  two  days  later.  The  family  physician  investigated  the  case  at  school,  con- 
cluding that  it  was  a  form  of  epilepsy.  The  boy  was  kept  from  school  and  put 
on  potassium  bromide.  The  attacks  becoming  more  frequent,  a  prominent 
neurologist  was  called  in  consultation  ;  the  same  treatment  was  continued.  He 
continued  to  have  attacks  every  day  and  very  often  twice  a  day,  lasting  from  five 
to  ten  minutes.  At  first  he  lay  unconscious,  without  any  movement  whatever ; 
then  the  attacks  became  violent,  frequently  requiring  several  men  to  hold  him 
down  and  prevent  him  from  doing  himself  bodily  harm.  The  former  consultant 
was  again  called  in  and  made  an  unfavorable  prognosis.  Several  neighboring 
physicians  who  had  been  called  during  the  attacks  gave  him  hypodermics  of  mor- 
phine. Patient  also  has  received  electrical  treatment  from  his  own  physician. 

Status  Prcesens.  — Face  pale,  covered  with  acne,  eyes  restless,  hand  tremu- 
lous, gait  unsteady,  appetite  fair  but  capricious,  gastric  oppression  after  meals, 
bowels  constipated.  Patient  appeared  to  be  brominized. 

Treatment. — Resorcin,  three  grains  in  half  a  pint  of  hot  water,  an  hour  before 
lunch  and  dinner.  He  was  ordered  to  be  at  once  well  scrubbed  with  soap  and 
water.  This  was  followed  by  a  wet  pack,  sheet  wrung  out  of  water  at  70°,  re- 
duced daily  two  degrees ;  this  to  be  followed  by  a  rain  douche  at  90°,  twenty- 
five  pounds  pressure,  gradually  reduced  during  thirty  seconds  to  75°. 

August  20th :  This  treatment  had  been  used  daily,  the  temperature  of  the 
douche  being  reduced  two  degrees  every  day.  He  had  a  slight  attack  five  days 
after  treatment  was  begun  ;  none  since.  He  was  ordered  to  Long  Branch  to  take 
surf  baths. 

September  29th.  Patient  has  called  on  me  several  times,  reporting  steady 
improvement.  He  was  discharged  cured.  The  patient  has  remained  well. 

Resume. — Hydrotherapy  is  regarded  by  the  author  as  an  essential 
element  in  the  management  of  hysteria;  not,  however,  by  reason  of 
any  specific  effect  of  cold  spinal  douches,  but  solely  on  account  of  its 
effect  upon  the  general  nutrition,  and  consequently  upon  the  nutrition 
of  the  nervous  system.  With  this  aim  constantly  in  view,  the  physi- 
cian will  accomplish  far  more  if  he  includes  some  form  of  water  treat- 
ment with  isolation,  rest  cure,  medicinal,* or  other  agents  which  he  may 
be  applying.  These  are  often  sufficient  to  restore  the  patient  to  health, 
but  the  path  to  recovery  will  surely  be  shortened  and  rendered  more 
agreeable  and  satisfactory  to  physician  and  patient  alike  by  the  judi- 
cious addition  of  water  in  some  procedure  best  adapted  to  the  case. 
Permanency  of  restoration  is  insured  by  hydrotherapy,  inasmuch  as 
the  patient  is  thus  trained  to  bear  and  like  some  form  of  home  treat- 
ment, as  daily  cold  affusions  or  plunges,  which  maintain  a  good  general 
and  nerve  nutrition. 


HYSTERIA.  459 

Functional  and  Other  Neuroses.  —The  author  has  obtained  striking 
results  from  hydrotherapy  in  many  neuroses,  especially  in  Graves'  dis- 
ease, chorea,  obstinate  headaches,  parcesthesias  of  various  types,  the 
traumatic  and  occupation  neuroses. 

The  management  of  cases  of  epilepsy  has  been  greatly  improved  in 
the  author's  hands  by  the  addition  of  tonic  hydrotherapy  to  the  bro- 
mides and  dietetic  measures.  The  plan  mapped  out  on  page  402  in 
the  management  of  neurasthenia  may  be  followed  in  these  cases,  when 
they  are  physically  depreciated ;  in  the  plethoric  and  obese  the  perspi- 
ration hot-air  bath  may  be  applied  with  advantage,  also  enteroclysis, 
to  free  the  intestinal  canal  of  ptomains,  scybalae,  etc.  The  following 
extract  from  Dr.  Foster's  report  for  1898  of  the  government  hospital 
for  the  insane  fully  bears  out  the  author's  personal  observation,  that 
bromide  acne  and  asthenia  are  decidedly  improved  or  avoided  in 
patients  subjected  to  methodical  hydrotherapy,  drip  sheet,  wet  packs 
and  douches,  as  indicated  in  each  case. 

Dr.  Foster  writes  (page  71):  "The  average  gain  in  which  the 
record  is  accurate  is  39.8  per  cent. 

"  It  is  gratifying,  upon  looking  up,  so  far  as  time  would  admit, 
what  has  been  written  upon  the  hydrotherapeutic  treatment  of  epi- 
lepsy, to  find  such  close  corroboration  of  results  which  have  been  ob- 
tained here." 

Fleury,  in  his  classic  work,  "Traite  therapeutique  et  critique 
d'hydrotherapie,"  Paris,  1875,  states  the  results  of  a  considerable  ex- 
perience as  follows: 

"  Of  all  methods  of  treatment  for  epilepsy  now  known,  hydrother 
apy  offers  the  most  numerous  and  surest  chances  for  success." 

The  statement  of  all  the  authors  consulted  agrees  with  these  conclu- 
sions of  Fleury. 

Weiss,  Duval  and  Delmas  report  cures.  Becquirel,  Frank,  Kosen- 
thal,  Marcet,  Nothnagel,  and  Bottey,  all  commend  the  treatment  in 
terms  similar  to  those  quoted  above. 

P.  Bricon,  in  his  doctor's  thesis  upon  the  treatment  of  epilepsy, 
gives  the  details  of  a  systematic  employment  of  this  treatment  at  the 
Bicetre,  1876-81,  in  the  service  of  M.  Bourneville.  An  examina- 
tion of  the  cases  shows  that  the  treatment  was  usually  continued  for 
about  two  months  without  cessation ;  sometimes  it  was  repeated ;  and 
in  one  case  extended  over  five  months. 

Of  46  cases  detailed,  34  showed  improvement.  In  17  of  the  latter 
there  was  no  other  treatment ;  and  in  10  of  these  the  improvement 
was  very  marked. 

In  a  more  recent  article  *  Bourneville  reports  as  the  result  of  twenty 
*  Le  Progr£s  Medical,  No.  6,  1903. 


460       THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

years'  observation  that  baths  and  douches  combined  with  gymnastic 
exercises  and  manual  labor  are  the  most  powerful  remedies  for  the 
various  forms  of  epilepsy  and  its  complications.  Bourneville  justly 
claims  that  under  simultaneous  applications  of  purgatives  and  hydro- 
therapy  the  bromide  salts  and  camphor  bromides,  which  he  regards  as 
the  most  effective  agents,  may  be  used  in  full  doses  without  detrimen- 
tal effects.  Cutaneous  activity  is  so  well  provided  for  that  he  has 
never  observed  a  case  of  brominism  under  this  management. 

The  author's  observation  is  thus  confirmed  by  reliable  clinicians. 
While  he  has  not  always  succeeded  in  preventing  acne,  he  has  felt 
greater  confidence  in  administering  large  doses  of  the  combined  bro- 
mides, from  which  he  has  not  observed  depreciating  constitutional 
effects  since  he  counteracted  the  latter  by  judicious  hydrotherapy, 
adapted  to  each  individual  case. 

Our  experience  would  seem  to  indicate  that,  in  long-standing  cases, 
improvement  is  less  marked  in  the  first  two  or  three  months  than  it  is 
later.  After  a  certain  gain  is  made  improvement  becomes  more  rapid. 
It  therefore  seems  quite  probable  that  the  average  treatment  at  the 
Bicgtre  was  too  short  for  the  best  results. 

Another  important  advantage  from  the  use  of  hydrotherapy  in  epi- 
lepsy is  mentioned  by  both  Fleury  and  Bottey,  namely,  in  admitting 
of  the  use  of  bromides  in  large  doses,  with  an  important  lessening  of 
its  ill  effects,  physical  and  mental.  This  is  accomplished  in  two  ways : 
By  facilitating  and  regulating  the  absorption  of  the  drug  it  permits  us 
to  obtain  the  same  effects  from  somewhat  smaller  doses ;  on  the  other 
hand,  by  its  stimulating  and  tonic  effects  upon  the  organism,  as  well 
as  by  its  favorable  action  upon  the  elimination  of  the  bromide  salt,  it 
incontestably  increases  tolerance  of  the  drug,  and  combats  its  ill  effects. 

The  hydriatric  management  of  these  affections  depends  upon  their 
etiology,  the  condition  and  environment  of  the  patient,  and  the  duration 
of  the  disease.  In  the  discussion  of  hydrotherapy  of  neurasthenia 
and  hysteria,  these  points  have  been  sufficiently  elaborated  to  warrant 
avoidance  of  repetition,  inasmuch  as  all  neuroses  may  be  treated  on  the 
lines  laid  down  for  these  diseases.  The  following  history  is  selected 
from  a  large  number : 

False  Angina. — Mr.  D ,  merchant,  aged  40  years,  weight  one  hundred 

and  ninety  pounds,  of  robust  appearance,  has  suffered  for  several  months  from  ago- 
nizing pains  in  the  precordial  region  whenever  he  attempted  to  walk  briskly,  espe- 
cially after  meals.  He  was  completely  disabled  from  business.  His  family  phy- 
sician regarded  the  case  as  one  of  angina  pectoris,  and  this  diagnosis  was  con- 
firmed by  an  eminent  consultant.  He  was  advised  to  use  amyl  nitrite  pearls  for 
the  attacks  and  give  up  business.  In  consequence  of  this  decision  he  became 
melancholic  and  when  he  applied  for  treatment  he  was  the  picture  of  woe.  He 
gave  a  gouty  history  ;  urine  normal  but  loaded  with  urates  ;  digestion  impaired ; 


HYSTEEIA.  461 

pulse  of  high  tension.  He  was  restricted  to  a  non-meat  diet,  put  upon  a  glonoin 
and  strychnine.  A  wet  pack,  water  at  60°,  was  ordered  daily  for  one  hour,  fol- 
lowed by  rapid  ablutions  with  water  at  50° ;  a  wet  compress  to  be  worn  all  day, 
wrung  out  of  water  at  60°.  No  preparatory  treatment  to  ascertain  his  reactive 
capacity  was  needed,  because  he  was  a  robust  man  of  splendid  physique.  The 
aim  of  treatment  was  the  enhancement  of  tissue  change,  a  calming  effect  with 
stimulating  sequel.  This  was  happily  accomplished,  because  the  patient  was 
careful,  and  frightened.  He  did  not  neglect  treatment.  He  almost  invariably 
slept  in  the  pack.  In  three  months  the  frequency  and  intensity  of  the  attacks 
had  so  far  diminished  that  I  permitted  him  to  take  a  journey  of  some  weeks.  On 
his  return  dyspeptic  symptoms  were  more  pronounced.  He  was  put  upon 
chopped  beef,  preceded  by  a  pint  of  hot  water  for  breakfast  and  dinner,  oysters 
and  hot  milk  for  luncheon.  Compresses  were  discontinued  ;  wet  packs  resumed 
daily  at  70°  F.  Four  months  later  he  was  entirely  free  from  pain,  had  lost  some 
flesh  but  was  able  to  bear  the  worries  of  business.  Although  five  years  have 
elapsed,  he  remains  in  good  health. 

The  same  result  has  been  achieved  in  other  less  intense  cases  by 
more  mild  hydriatic  procedures,  ablutions,  and  douches.  Failures  are, 
however,  not  rare.  In  a  case  referred  to  me  by  Prof.  William  Osier, 
of  Baltimore,  the  most  assiduous  hydrotherapy  for  a  period  of  four 
months  failed  to  make  any  impression. 


CHAPTER   XXVI. 

CHRONIC  RHEUMATISM  AND  GOUT. 

THE  prognosis  in  these  diseases  is  unfavorable,  chiefly  because  the 
diagnosis  is  not  always  exact,  and  the  treatment  consists  mainly  of 
medicinal  agents.  Large  clinical  material  has  convinced  the  author 
that  cases  of  pure  chronic  articular  and  muscular  rheumatism  offer  a 
prolific  field  for  physical  remedies.  Skilful  massage  and  resisting 
movements,  combined  with  judicious  hydrotherapy,  are  capable  of  ac- 
complishing, as  Professor  Semmola*  has  truly  said,  "  marvels  of  resto- 
ration in  the  most  desperate  cases." 

Winternitz  has  observed  that  faradization  of  painful  rheumatic 
joints  produces  an  anaesthesia  furthering  hydriatic  and  massage  treat- 
ment, which  is  otherwise  precluded  by  the  pain. 

The  cases  of  chronic  rheumatism  which  have  come  under  my  own 
care  may  be  divided  for  therapeutic  purposes  into  the  well-nourished 
and  the  anaemic. 

In  the  well-nourished  rheumatic  subject,  full  baths  of  eight  to  fifteen 
minutes'  duration,  in  water  at  95°,  rapidly  raised  to  a  higher  tempera- 
ture up  to  tolerance,  usually  106°  to  110°,  with  gentle  massage,  are 
the  most  useful  procedure,  combined  with  the  internal  use  of  very  cold 
water  to  stimulate  excretion  by  the  kidneys.  As  is  customary  in  the 
excellent  baths  at  Mount  Clemens,  the  hot  springs  of  Virginia  and 
Arkansas,  Paso  Robles,  California,  where  I  introduced  it  in  1905,  in 
Baden  bei  Wien,  Gastein,  Aachen,  and  other  more  or  less  renowned 
thermal  resorts,  the  patient  should  receive  a  prolonged  warm  bath, 
with  massage  during  the  bath;  perspiration  should  be  promoted  by 
a  prolonged  dry  puck  in  woollen  blankets.  The  elimination  of  ele- 
ments of  imperfect  metabolism  is  the  chief  aim  of  this  treatment.  The 
marvellous  results  from  bathing  in  the  hot  mineral  springs  are  not  at- 
tributable, in  the  writer's  opinion,  to  absorption  of  the  mineral  ingre- 
dients of  the  waters,  but  to  the  judicious  methods  of  their  application 
by  experienced  physicians,  together  with  the  freedom  from  business 
or  other  cares  and  the  influence  of  a  changed  mode  of  life. 

Many  will  be  inclined  to  be  sceptical  upon  this  point,  so  firmly 
rooted  is  the  idea  in  the  minds  of  medical  men  that  these  baths  produce 
their  effect  largely  by  absorption  of  their  chemical  constituents.  For- 
tunately we  have  sufficiently  positive  experiments  to  decide  this  ques- 
*  Lectures  on  Therapeutics  at  Naples  University. 


CHRONIC  RHEUMATISM  AND  GOUT.  463 

tion  and  to  remove  any  doubt  that  may  exist.  Among  many  of  these  ob- 
servations are  those  of  Stas,  *  who  subjected  himself  on  three  successive 
days  to  baths  of  86°  to  90°,  containing  fifty  milligrams  of  arsenate  of 
sodium  to  the  litre.  Although  he  remained  in  this  bath  for  prolonged 
periods,  not  the  slightest  absorption  was  noted.  The  same  result  was 
obtained  from  baths  of  iodide  of  potassium  and  other  salts,  which  could 
be  readily  recognized  in  the  urine  if  they  had  been  absorbed.  I  do  not 
claim  that  this  negative  result  militates  against  the  general  impression 
that  such  mineral  baths  are  exceedingly  useful  and  effective  therapeu- 
tically.  On  the  contrary,  we  have  here  suggestive  climatic  and  hy- 
gienic elements,  besides  the  local  and  general  temperature  effects. 
Just  as  the  imbibition  of  mineral  water,  strongly  impregnated  with 
purgative  or  other  salts,  offers  immediate  evidence  of  their  imbition, 
there  is  in  the  temperature  effect  of  baths  similar  evidence  of  action. 
The  heat  or  cold  conveyed  by  the  peripheral  cutaneous  nerves  to  the 
central  nervous  system,  and  thence  reflected  through  the  motor  tracts, 
is  the  really  effective  element  in  the  mineral  baths.  The  latter  are 
aided  by  only  such  ingredients  as  stimulate  the  cutaneous  nerves,  e.g., 
strong  saline  or  C0a  constituents.  Other  mineral  ingredients  >  are  in- 
different in  their  effect  upon  the  skin,  and,  as  has  been  shown,  utterly 
incapable  of  entering  the  system  by  cutaneous  imbibition.  These  are 
facts  substantiated  by  exact  experimentation — facts  which  must  unset- 
tle long-cherished  ideas  and  arouse  a  healthy  scepticism  in  the  minds 
of  medical  men,  and  induce  them  to  trust  more  frequently  to  the 
thermic  and  mechanical  effect  of  pure  water,  i.e.,  hydrotherapy. 

If  physicians  would  more  carefully  study  the  practice  of  the  excel- 
lent medical  men  who  devote  their  lives  to  the  study  and  application 
of  mineral  waters  in  disease,  they  would  become  familiar  with  facts  and 
methods  which  would  enable  them  to  imitate  the  effect  of  these  waters 
at  home,  in  such  individuals  as  are  unable  or  unwilling  to  be  removed 
to  the  hot  mineral  springs,  which  must  always  remain  the  most  valua- 
ble remedial  agents  in  chronic  rheumatism  and  gout. 

Prolonged  hot  baths,  therefore,  followed  by  sweating  in  blankets, 
are  useful  for  robust-looking  rheumatic  and  gouty  people.  These  may 
be  repeated  daily,  as  the  physician's  judgment  may  decide.  During 
the  interval  between  the  baths,  wet  compresses  at  65°,  covered  with 
flannel  or  wadding,  left  on  until  nearly  dry,  may  be  profitably  wrapped 
around  the  tender  or  swollen  joints.  These  may  be  worn  during  the 
night  also. 

After  the  subacute  condition  has  subsided,  the  hot-air  bath,  in 
which  the  patient  is  allowed  to  perspire  for  five  to  fifteen  minutes,  fol- 
lowed by  the  circular  douche  at  100°,  reduced  gradually  to  90°,  during 
*  La  Presse  Medicale  Beige,  1886,  No.  13. 


464       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

one  or  two  minutes,  with  a  pressure  of  twenty-five  pounds,  followed 
by  a  strong  Scotch  douche  to  the  joints  for  fifteen  seconds,  is  a  useful 
procedure.  The  elimination  of  retained  products  of  tissue  change  is 
greatly  enhanced  by  this  procedure,  if  it  is  resorted  to  daily  or  at  least 
triweekly. 

'Ike  Scotch  douche  is  a  procedure  which  also  aids  the  absorption  of 
local  deposits. 

Without  detailing  the  histories  of  his  own  cases,  the  author  will 
follow  the  plan  of  adducing  the  testimony  of  other  reliable  observers 
who  are  not  hydrotherapists. 

Prof.  Max  Schuller*  presented  to  the  XXI.  Surgical  Congress  his 
views  on  this  subject.  He  acknowledges  the  value  of  diet  and  climate, 
but  claims  to  have  obtained  no  result  from  potassium  iodide  and  mer- 
cury, etc.  Massage  of  the  muscles  (not  the  joints),  combined  with 
baths,  is  his  chief  reliance.  His  best  results  have  been  obtained  from 
sweating  in  woollen  blankets,  followed  by  cold  wet  rubbing.  Most  of 
these  patients  go  year  after  year  from  one  hot  spring  to  another.  He 
has  had  better  results  from  the  use  of  the  Scotch  douche  than  from  the 
other  forms  of  hydrotherapeutic  applications  in  this  difficult  class  of 
cases. 

"  The  Scotch  douche  consists  of  the  quick  alternation  of  streams  of 
hot  and  cold  water,  in  a  stream  of  about  the  size  of  the  little  finger  and 
of  a  constantly  varying  pressure,  delivered  from  the  same  nozzle.  This 
douche  is  not  so  well  known,  says  Dr.  Schuller,  as  it  should  be,  and 
was  not  found  in  a  number  of  bathing-resorts  visited  by  him.  Its 
good  effects  are  shown  by  a  restoration  of  the  thickened  joint  capsule 
and  by  a  strengthening  of  the  muscular  apparatus.  The  douche  should 
always  be  used  after  warm  baths,  which  are  often  administered  at  too 
high  a  temperature  at  the  bath  establishments. 

"  The  Scotch  douche  has  other  advantages  in  the  facts  that  it  can  be 
regulated  very  easily  as  to  temperature,  that  it  can  be  borne  by  weak 
patients,  and,  above  all,  that  it  conveys  a  distinct  mechanical  effect, 
along  with  its  thermal  effect,  upon  the  vessels  and  muscles.  This 
treatment  is  ordinarily  soon  followed  by  a  diminution  of  pain  and  an 
increased  motility  of  the  joint.  Many  cases  can  be  kept  for  years  in 
an  endurable  condition  by  this  means,  which  would  otherwise  be 
attended  by  great  suffering.  In  cases  that  are  marked  by  a  relative 
immobility  due  to  a  shrinking  and  contraction  of  the  capsule,  but  not 
due  to  true  ankylosis,  the  Scotch  douche,  with  an  especially  delicate 
massage  and  passive  motion,  will  assist  materially  in  the  increase  of 
mobility.  Schuller  has  practically  observed  this  among  those  of  his 
patients  who  had  been  affected  in  the  wrist  and  ankle  joints.  The 
great  susceptibility  to  pain  which  attends  these  cases  will  not  admit  of 
*  Langenbeck's  Archiv,  Bd.  xlv. .  41. 


CHRONIC   RHEUMATISM   AND   GOUT.  465 

the  most  delicately  applied  massage,  if  the  latter  is  tried  without  the 
douche ;  but  with  the  combination  these  patients  feel  better,  walk  or 
move  their  limbs  with  less  difficulty,  and  experience  much  less  pain,  so 
long  as  the  treatment  is  continued."  (See  Steam  Scotch  Douche.) 

2.  In  the  ill-nourished  sufferer  from  chronic  rheumatism,  the  hot- 
bath  treatment  must  be  used  with  great  caution.  The  relaxation  inci- 
dent to  these  baths  and  the  subsequent  sweating  procedures  are  useful, 
if  they  be  not  repeated  too  often.  Twice  a  week  is  the  maximum  num- 
ber. The  debilitating  effect  may,  however,  be  counteracted  by  other 
hydriatric  procedures.  A  daily  ablution  with  water  gradually  reduced 
one  or  two  degrees  for  each  occasion,  and  followed  by  the  procedures  as 
indicated  under  the  caption  of  anaemia,  not  only  counteracts  these 
effects,  but  tends  to  raise  the  vascular  tone  and  with  it  increase  elimi- 
nation. The  lowest  possible  temperatures  and  brief  duration  consis- 
tent with  good  reaction  are  the  acme  of  treatment  for  this  type  of 
rheumatics. 

The  Scotch  douche  to  the  joints  and  subsequent  wrapping  in  wet 
compresses  are  useful  auxiliaries.  An  excellent  mode  of  managing 
these  depreciated  individuals  is  the  dry  pack  (described  on  page  413), 
after  which  the  whole  body  is  rapidly  dried  and  treated  to  friction,  the 
joints  are  wrapped  in  damp  compresses  at  60°,  and  the  underclothing 
is  resumed.  By  this  method  many  patients  suffering  from  subacute  or 
chronic  rheumatism  may  be  rendered  capable  of  locomotion,  their  nutri- 
tion improved,  and  gradually  restored  to  health.  If  this  treatment  be 
not  sufficient,  the  hot-air  bath  may  be  resorted  to  twice  or  thrice  a 
week,  followed  by  rapidly  reduced  rain  baths  and  douches,  as  detailed 
above.  On  alternate  days  the  hot-air  bath  short  of  perspiration  and 
followed  by  a  one-minute  circular  douche  of  90°-85°  and  a  fan  douche 
for  fifteen  seconds  under  pressure  of  twenty  pounds  daily  increased  one 
pound,  and  of  a  temperature  reduced  daily  until  50°  is  reached  without 
distress,  and  succeeded  by  a  fifteen-second  Scotch  douche  to  the  swollen 
or  painful  parts,  offer  a  most  efficient  tonic  and  alterative  measure. 

This  gradual  accustoming  of  the  usually  timid  patient  to  lower 
temperatures  and  higher  pressure  educates  the  reactive  capacity, 
refreshes  and  invigorates  him,  improves  oxygenation,  and  sends  the 
blood  in  joyous  currents  through  his  sluggish  circulatory  apparatus. 
Local  congestions  are  removed,  the  circulation  of  the  joints  is  improved, 
stiffness  is  diminished ;  not  infrequently  not  only  is  the  patient  restored, 
but  recurrences  which  have  embittered  his  life  are  prevented  by  his 
accustoming  himself  to  cold  ablutions  or  plunges  on  rising  every 
morning. 

In  very  rebellious  cases  of  chronic  rheumatism  and  gout,  the  douche- 
massage,  as  practised  at  the  Arkansas  and  Virginia  Hot  Springs  in 
30 


466       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

this  country,  and  at  Aix-les-Bains  and  Aix-la-Chapelle,  is  very  useful 
(Fig.  74). 

The  mineral  ingredients  of  the  water  are  of  little  consequence,  as 
has  been  shown  above.  The  temperature  and  pressure  under  which 
it  is  delivered,  and  the  skilful  manner  in  which  the  douche  is  combined 
with  massage,  however,  render  this  treatment  extremely  effective.  Each 
joint  may  be  separately  treated  by  douche-massage.  In  these  thermal 
resorts  the  patient  is  advised  to  lie  in  warm  blankets,  being  carried  in 
a  Sedan  chair  at  Aix-les-Bains,  or  upon  an  elevator,  as  in  the  new 


FIG.  74.— The  "Aix"  Douche  Massage  (after  Qlax). 

Kaiserbad  at  Aix-la-Chapelle,  to  his  rooms,  or,  as  is  better  done  at  the 
Virginia  Hot  Springs,  placed  on  a  cot  adjoining  the  douche  room, 
upon  which  he  remains  until  perspiring  abundantly. 

This  bath  may  be  imitated  in  any  institution  where  an  apparatus 
for  douches  exists  with  facilities  for  regulating  temperature  and  pres- 
sure, but  it  is  impossible  to  imitate  the  environment. 

The  treatment  of  chronic  rheumatism,  which  is  now  left  too  often 
in  the  hands  of  lay  and  medical  empirics,  may  become  satisfactory  to 
physician  and  patient  alike,  if  judicious  hydrotherapy  be  made  the  chief 
factor,  applied  in  accordance  with  the  demands  of  each  individual  case, 
and  as  carefully  watched  as  in  a  case  of  pneumonia  or  other  acute  dis- 


CHRONIC  RHEUMATISM  AND   GOUT.  467 

ease.  Slipshod  treatment,  be  it  medicinal,  dietetic,  climatic,  hydro- 
therapeutic,  or  otherwise,  may  be  charged  with  many  failures  in  these 
as  in  other  chronic  diseases.  The  assiduous  study  of  the  peculiarities 
of  each  case,  on  the  other  hand,  and  the  adaptation  of  the  temperature 
and  duration  of  each  hot  bath,  will  enable  the  family  physician  to  retain 
these  cases  under  his  own  care  and  thus  prevent  the  necessity  of  their 
leaving  home  and  family. 

This  individualization  is  of  prime  importance;  its  disregard  has  led 
to  disappointment  and  sorrow  more  frequently  than  has  regard  for  it 
been  crowned  with  success.  As  a  result  of  a  quarter  of  a  century's 
observation  in  private  and  hospital  work  the  author  has  been  led  to 
divide  his  cases  of  "chronic  rheumatism"  (so  called)  into  certain 
groups  for  therapeutic  purposes. 

1st.  Affections  of  the  larger  joints,  occurring  in  persons  who  have 
passed  through  one  or  more  attacks  of  acute  articular  rheumatism; 
more  frequent  in  men  than  in  women. 

2d.  A  slowly  developing  type,  in  which  one  or  more  joints,  usually 
the  knee,  ankle,  shoulder,  or  elbow,  are  gradually  invaded.  To  this 
type  may  be  added  gonorrhceal  rheumatism. 

The  management  of  these  types  may  conveniently  be  grouped  to- 
gether. Hot-air  baths  and  Turkish  baths  are  contraindicated.  De- 
manding considerable  exertion,  they  materially  increase  local  inflam- 
matory action,  which  is  enhanced  also  by  the  irritating  effect  of  great 
heat  upon  the  affected  joints  and  by  their  depreciating  action  upon  the 
heart.  Especially  the  Turkish  bath  in  which  the  patient  is  forced  to 
breathe  very  hot  air  in  ill- ventilated  rooms  has  proved  disastrous  and 
discouraging  in  these  types.  Procedures,  on  the  contrary,  which  induce 
heat  stasis  are  of  the  utmost  advantage.  In  a  comfortably  warm 
room  a  bathtub  is  filled  two- thirds  with  water  at  95°.  The  patient, 
having  had  his  face  bathed  with  ice  water  and  his  head  wrapped  in 
a  cold  wet  compress,  is  carefully  placed  in  the  tub.  Water  from  the 
hot  faucet  is  added  until  the  temperature  reaches  105°  on  the  first  day, 
and  this  is  daily  increased  one  degree  until  108°  or  110°  F.  is  reached. 
The  duration  should  be  five  minutes,  or  less  if  patient  is  distressed,  but 
should  be  increased  daily  one  minute  until  ten  is  reached  without  dis- 
tress. During  this  entire  period  the  affected  joints  or,  if  very  painful, 
their  neighboring  structures  should  receive  stroking  finger  massage. 
When  removed  from  the  bath,  patient  should  be  wrapped  in  a  previ- 
ously prepared  hot  linen  sheet,  and,  without  being  dried,  placed 
upon  three  woollen  blankets.  The  latter  should  be  wrapped,  with 
careful  avoidance  of  pain,  around  the  patient,  in  order  to  con- 
tinue heat  retention,  for  an  hour,  or  less  if  patient  be  actually  dis- 
tressed. During  this  pack  the  face  is  bathed  in  ice  water,  the  cold 


468       THE   PRINCIPLES   AND   PRACTICE  OF   HYDROTHERAPY. 

turban  renewed,  and  two  ounces  of  ice  water  are  administered  every  ten 
minutes;  a  window  is  opened  sufficiently  to  ventilate  the  room  thor- 
oughly but  not  to  reduce  its  temperature  materially.  In  intractable 
cases  the  author  has  prolonged  this  pack  two  to  six  hours,  renewing  bath 
and  pack  after  rest  and  attention  to  the  bladder  and  intestines.  Prior 
to  removal  the  window  is  closed  and  the  room  warmed.  Now 
the  blankets  and  sheet  are  unwrapped  over  the  trunk.  The 
latter  is  dried  with  warm  cloths  and  receives  rapid  friction  with 
diluted  but  not  warmed  alcohol.  The  lower  parts  are  similarly  treated. 
The  patient  is  cautiously  turned,  and  the  posterior  parts  of  the 
body  are  also  dried  and  rubbed  with  alcohol,  after  which  he  is  placed 
in  bed.  It  is  preferable  to  prepare  this  pack  on  one  side  of  the  bed 
(in  home  treatment)  and  thus  avoid  exertion  by  simply  withdrawing 
the  pack.  If  this  technique  has  been  scrupulously  followed  profuse 
diaphoresis  will  ensue  in  the  pack.  It  has  been  found  advantageous 
to  omit  the  bath  once  or  twice  each  week  and  subject  the  patient  to  a 
tonic  procedure  instead,  viz.,  rapid  ablutions  of  60°  or  less,  or,  if  pain 
is  not  materially  increased  by  exertion,  the  hot-air  bath  (short  of  per- 
spiration) followed  by  the  circular  douche  at  95°  for  one  minute  and 
the  fan  douche  at  85°  F.  daily  reduced  for  half  a  minute.  These 
tonic  procedures  need  to  be  more  frequent  than  the  eliminative  in 
cases  of  decided  enfeeblement  or  great  loss  of  weight.  The  latter  is 
apt  to  result  in  obese  patients,  in  whom  tissue  change  appears  to  be 
greatly  enhanced  by  the  above-detailed  heat-retaining  procedures.  In 
this  method  the  flexibility  of  hydrotherapy  is  evident,  in  that  the 
physician  is  enabled  to  meet  every  indication  of  the  case.  During  the 
interval  between  baths  a  wet  compress,  consisting  of  two  folds  of  old 
linen,  should  be  wrapped  around  the  affected  joints  and  covered 
snugly  with  one  layer  of  flannel,  secured  by  pins.  This  may  be  re- 
newed every  four  hours. 

3d  Type. — This  is  true  gout,  of  subacute  character,  sometimes  but 
not  often  a  sequel  of  acute  gout.  It  begins  with  pain  and  stiffness  of 
the  smaller  joints,  phalangeal  and  tarsal,  and  not  rarely  extends  to 
the  wrists,  elbows,  and  ankles.  Almost  invariably  ansemia  and  gen- 
eral systemic  depreciation  are  manifested.  This  type  is  frequently 
distinguished  by  neurasthenic  complications. 

4th  Type. — This  is  the  so-called  muscular  rheumatism,  which  most 
commonly  begins  in  the  loins,  as  lumbago,  and  affects  later  the  erector 
spinae  and  other  dorsal  muscles,  and  sometimes  the  group  of  muscles 
originating  in  the  sacro-iliac  region. 

When  thoroughly  established  these  types  occur  so  often  in  depre- 
ciated individuals  that  special  care  is  required  in  their  management. 
Being  usually  of  subacute  character,  they  bear  the  Turkish  bath  very 


CHRONIC   RHEUMATISM   AND   GOUT.  469 

badly;  stiffness  is  sometimes  relieved  by  the  sweating  and  shampoo- 
ing incident  to  the  latter,  but  in  the  majority  of  cases  the  relief  is 
transient  and  the  system  is  greatly  debilitated  by  them.  It  is  unfor- 
tunate that  these  baths  are  so  often  prescribed  by  physicians  who  thus 
deliver  their  helpless  patients  into  the  hands  of  rough  men  and  women 
who  are  accustomed  to  deal  chiefly  with  bon-vivants,  plethoric  and 
otherwise  healthy  or  robust  persons,  or  the  obese  in  search  of  reduc- 
tion of  the  waist  line — individuals  who  are  capable  of  enduring  their 
heroic  manipulations.  In  cases  of  the  third  and  fourth  group  it  is 
advisable  to  proceed  carefully,  beginning  with  dry  packs,  as  described, 
to  accumulate  heat  on  the  skin,  followed  by  rapid  ablutions  with  water 
beginning  at  90°  F.  and  reducing  daily  two  or  more  degrees  until  60° 
is  reached.  In  less  depreciated  cases  the  following  formula:  $ 
Hot-air  bath  until  perspiration  is  observed,  followed  by  a  circular 
douche  at  fifteen  pounds'  pressure  and  temperature  of  100°,  gradually 
reduced  to  95°  F.  for  one  minute  and  followed  by  a  fan  douche  at  twenty 
pounds'  pressure,  slowly  passed  up  and  down  over  entire  body,  water 
at  90°,  reduced  to  85°  F.  for  thirty  seconds.  The  last  temperature 
may  be  reduced  one  degree  every  day,  until  60°  F.  is  reached  with- 
out impairment  of  reaction.  The  latter  must  always  be  guardedly 
secured.  This  treatment  cannot  be  administered  at  the  patients' 
home,  because  an  easily  regulated  apparatus  is  required.  With  proper 
precaution  against  cardiac  enfeeblement  the  above  full-bath  treatment 
may  be  substituted,  until  the  douche  method  can  be  procured  in  an 
institution. 

Rheumatoid  arthritis  being  an  incurable  disease,  efforts  to  maintain 
the  digestive  and  assimilative  organs,  relieve  pain,  procure  sleep,  and 
diminish  stiffness  are  indicated.  As  in  all  chronic  cases,  change  of 
environment,  attention  to  diet  and  hygiene  are  important.  The  effect 
of  these  may  be  enhanced  by  judicious  tonic  hydrotherapy.  Diapho- 
retic procedures  should  be  avoided;  the  skin  should  be  exposed  to  suffi- 
cient heat  only  to  improve  reaction  for  neuro- vascular  training,  which 
is  very  useful  in  these  cases.  After  an  hour's  dry  pack  or  a  few  min- 
utes' warming  in  a  hot-air  box,  the  patient's  trunk  should  be  rapidly 
treated  to  ablutions  with  water  beginning  at  90°,  and  daily  reduced 
one  degree  until  60°  or  less  is  reached  without  chilling.  Each  part 
should  be  dried  quickly  (see  Ablutions  and  Affusions).  The  circular 
and  fan  douches  of  low  pressures  and  temperatures  not  below  80°  are 
useful  tonic  procedures  at  institutions  or  springs  possessing  hydro- 
therapeutic  apparatus. 

The  most  useful  procedures  in  "  rheumatism  "  have  been  detailed 
somewhat  at  length  by  reason  of  their  well-established  value  in  the 
hands  of  the  judicious  practitioner.  Especially  do  baths  deserve 


470       THE  PRINCIPLES  AND   PRACTICE  OF  HYDROTHERAPY. 

the  serious  attention  of  the  family  physician,  who  rarely  has  had  op- 
portunity to  observe  them  in  his  earlier  studies  at  college  or  hospital. 
The  value  of  these  simple  procedures  carefully  executed  consists  not 
only  in  the  relief  afforded,  but  in  the  saving  to  patients  of  deprivations 
and  expenses  incident  to  journeys  to  springs,  and  preventing  their 
falling  into  the  hands  of  bath,  massage,  electric,  or  osteopathic  charla- 
tans. 


CHAPTER 

DYSPEPSIA. 

ALTHOUGH  but  one  manifestation  of  functional  and  organic  diseases 
of  the  stomach,  dyspepsia  or  difficult  digestion — i.e.,  abnormal  diges- 
tion— is  the  chief  symptom,  and  this  is  the  author's  reason  for  grouping 
all  functional  diseases  of  the  stomach  together  for  the  purpose  of  illus- 
trating their  hydriatic  treatment. 

Without  entering  into  a  detailed  account  of  the  gastric  diseases 
with  abnormal  digestion,  it  is  my  purpose  to  consider  the  two  most 
prominent  types — 1,  gastric  catarrh ;  and  2,  nervous  dyspepsia — because 
in  both  the  patient  is  conscious  of  abnormal  sensations  in  or  around  the 
stomach,  and  his  general  discomfort  occurs  chiefly  after  meals.  In  all 
cases  proper  attention  to  environment,  diet,  exercise,  rest,  and  favor- 
able hygienic  conditions  are  of  prime  import. 

In  gastric  catarrh  we  have  to  deal  with  a  stomach  whose  motor  and 
secretory  capacity  is  more  or  less  impaired.  The  circulation  in  the 
mucous  coat  is  sluggish;  hence  the  secretions  are  diminished  and 
absorption  is  greatly  embarrassed.  Sooner  or  later  the  motor  capacity 
fails  decidedly.  To  restore  the  mucous  coating  to  a  normal  condition,  to 
remove  accumulated  mucus  and  products  of  fermentation,  and  to 
enhance  the  peristaltic  action  of  the  organn,  are  the  chief  indications 
of  treatment.  The  restoration  of  normal  circulation  in  the  diseased 
mucosa  is  accomplished  by  general  tonic  procedures.  For  the  removal 
of  abnormal  products  lavage  may  be  applied,  as  directed  on  page  269. 

The  defective  motor  capacity  of  the  stomach  in  these  cases  is 
favorably  influenced  by  general  tonic  hydrotherapy.  These  patients 
may  be  more  quickly  trained  to  bear  water  at  low  temperatures  and 
under  strong  pressure  than  any  other  class.  If  they  are  anaemic,  it  is 
my  custom  to  order  daily  ablutions,  beginning  with  85°,  followed  by 
good  friction,  as  detailed  under  the  caption  of  Anaemia,  page  403.  If 
these  measures  do  not  fulfil  all  the  indications,  the  dripping-sheet 
(page  108)  or  cold  rub  may  be  administered  on  rising  from  bed,  fol- 
lowed by  friction  and  a  brisk  walk.  Next  in  order  follow  jet  and  fan 
douches  of  80°,  daily  lowered  two  or  more  degrees.  These  will  be 
more  effective,  the  therapeutic  aim  being  an  enhancement  of  circulation 
in  the  muscular  structures  and  removal  of  the  hypochondriasis  often 


472       THE  PRINCIPLES  AND   PRACTICE  OF   HYDKOTHEEAPY. 

incidental  to  this  malady.  The  latter  is  often  diminished  by  adding 
strong  spinal  douches  of  very  low  temperatures  (Charcot)  to  the  gen- 
eral treatment.  This  treatment  must  be  judiciously  adapted  to  each 
individual  case,  and  modified  according  to  effects  and  indications. 

As  a  local  motor  stimulant  I  have  found  the  Scotch  douche  (alter- 
nating from  60°  to  110°)  to  the  epigastrium,  a  little  below  and  to  the 
left  of  the  ensiform  cartilage,  a  very  valuable  auxiliary,  if  begun  with 
a  pressure  of  ten  pounds  and  increased  daily  two  pounds  up  to  thirty. 

It  is  not  unreasonable  to  suppose  that  the  general  enhancement  of 
circulatory  conditions  must  react  favorably  upon  the  gastric  mucous 
membrane  and  its  glands.  Clinical  proof  of  this  claim  is  abundant. 

Nervous  dyspepsia  is  an  affection  which  prevails  to  the  greatest 
extent  in  the  large  commercial  centres,  where  sedentary  life  renders 
the  individual  more  receptive  to  the  pernicious  influences  of  the  strain 
which  the  nervous  system  is  called  upon  to  bear  by  reason  of  the  strug- 
gle for  existence,  the  competitions,  the  worries,  and  the  anxieties  of 
modern  life. 

It  may  be  mentioned  en  passant  that  next  to  out-door  exercise,  which 
is  rarely  to  be  commanded,  the  daily  cold  plunge  is,  as  the  author  has 
elsewhere  endeavored  to  impress,  the  most  valuable  prophylactic  against 
this  overstrain.* 

In  the  treatment  of  these  cases,  removal  from  unfavorable  environ- 
ment is  the  prime  indication,  but  one  which  is  rarely  capable  of  being 
met.  When  the  patient  cannot  leave  home,  or  is  not  benefited  by  the 
usual  treatment,  a  course  of  hydrotherapy  offers  the  best  chance  to  him, 
provided  he  limit  his  work  or  abandons  it  entirely.  The  following 
illustrate  the  treatment  in  such  cases,  and  afford  an  insight  into  the 
procedures  best  adapted  to  them. 

CASE  I. — Mrs.  O ,  aged  28  years,  resident  of  Florida,  consulted  me  on  May 

5th,  for  "catarrh  of  the  stomach,"  because  of  agonizing  pains  after  meals. 
She  has  been  living  on  mush  and  milk,  and  has  had  medical  treatment  for  several 
years,  with  diminution  but  not  disappearance  of  the  pains.  She  is  emaciated ; 
her  voice  is  feeble ;  she  is  depressed  and  hopeless.  Her  wan  face  and  prematurely 
old  appearance  bear  evidence  of  a  life  of  constant  physical  suffering.  There  is 
not  a  particle  of  the  hysteric  element  in  this  case.  Ordered  at  12  :  30  P.M.  a  full 
test  meal  at  Delmonico's,  which  she  reluctantly  accepted  because  of  dreaded  in- 
crease of  pain.  Five  hours  later  the  stomach  was  washed  out  without  difficulty, 
Mrs.  O.  displaying  marked  patience.  To  her  great  surprise,  my  prediction  that 
her  dinner  would  be  digested  was  verified,  a  little  tomato  peel  being  the  only 
remnant  visible. 

The  diagnosis  of  a  gastric  neurosis  being  clear,  she  was  ordered  a  mixed  diet, 
chiefly  consisting  of  hot  milk  and  stale  bread  and  hominy  for  breakfast,  adding 

*  Article  "Hydrotherapy  and  Mineral  Springs.  "  by  Simon  Baruch,  M.D., 
p.  454,  vol.  i.,  Hare's  "System  of  Practical  Therapeutics." 


DYSPEPSIA.  473 

eggs  (soft  boiled)  later,  same  with  fish  or  oysters  for  luncheon,  and  steamed  rice 
and  roast  beef  for  dinner.  Desserts  and  salads  forbidden. 

The  general  invigoration  of  the  entire  system  being  the  chief  indication  in 
this  case,  she  was  placed  upon  daily  hydriatic  measures  adapted  to  her  case,  by 
gradually  accustoming  her  to  lower  temperature  and  stronger  pressures. 

May  6th.  She  received  a  hot-air  bath  (169°  F.)  for  six  minutes,  which  pro- 
duced cutaneous  hypersemia  and  some  perspiration.  This  was  followed  by  a  tub 
bath  of  98°  for  five  minutes,  with  friction.  Upon  emerging  she  was  subjected  to 
a  rain  douche  of  95°,  reduced  to  90°  during  half  a  minute,  at  twenty  pounds  pres- 
sure. The  treatment  was  terminated  by  a  spray  douche  at  80°  for  five  seconds, 
with  friction. 

She  received  no  warm  tub  baths  on  the  following  day,  but  was  at  once  sub- 
jected after  the  hot-air  bath  to  a  rain  douche  of  90°,  reduced  to  80°,  for  thirty 
seconds  and  a  fan  douche  of  70°  for  five  seconds.  Reaction  was  fair. 

May  25th.  A  jet  douche  to  back  at  60°  was  added  on  account  of  hypochon- 
driasis. 

June  12th.  Same  treatment,  except  that  jet  douche,  having  been  daily  lowered 
one  degree,  now  reached  48°.  She  improved  steadily,  gaining  flesh  and  being 
brighter  and  more  cheerful. 

June  18th.     The  jet  douche,  proving  too  exciting,  was  suspended. 

June  20th.  She  complained  of  epigastric  pain  and  received  the  constant  cur- 
rent, twelve  miliamperes,  applied  by  a  large  flat  sponge  electrode  over  epigas- 
tric and  a  small  one  over  lumbar  region.  Temperature  of  douche  was  raised 
to  75°. 

June  27th.  Temperature  of  douche  was  now  reduced ;  she  was  again  de- 
pressed ;  the  jet  douche  given  at  50°  for  three  seconds.  Reaction  good. 

July  9th.  Electricity  having  been  unavailing  and  fermenting  material  having 
been  found  in  the  stomach,  the  Scotch  douche  has  been  daily  applied  to  epigastric 
region  for  thirty  seconds  after  the  rain  douche,  70°-45°  daily,  and  followed  by 
jet  douche  at  50°  for  three  seconds.  Patient  returned  to  Buffalo  to  her  parents. 

On  November  26th,  1892,  she  wrote  that  she  had  gained  fifteen  pounds  in 
weight  and  was  much  stronger ;  had  continued  the  diet  prescribed,  because,  like 
most  of  these  neurotics,  she  "feared  her  stomach  was  not  equal  to  much  of  a 
change."  Most  of  the  time  she  is  entirely  free  from  pain  ;  she  has  slight  distress 
every  now  and  then,  but  expresses  the  warmest  gratitude  for  the  help  given. 

CASE  II. — Dr.  H asked  me  to  give  him  lavage.  He  looked  baggard, 

suffered  from  migraine ;  had  worked  in  country  practice  on  Long  Island  for 
years ;  vomited  often,  with  headache ;  had  tried  everything,  including  rest  for 
eight  months,  dieted  very  carefully,  and  had  recently,  under  one  of  our  most 
eminent  consultants,  who  regarded  him  as  suffering  from  gastric  catarrh,  con- 
fined himself  to  hot  water  and  chopped  beef  without  avail.  He  had  section  of 
the  external  rectus  done  on  both  eyes  by  an  enthusiast  on  the  subject.  Thought 
he  was  astigmatic,  which  Dr.  Carl  Koller  did  not  concur  in.  My  diagnosis  of 
nervous  dyspepsia  was  confirmed  by  lavage,  which  showed  perfect  digestion  of 
a  full  and  varied  meal  taken  five  hours  previously.  A  mixed  diet  consisting  of 
meat,  farinaceous  food,  excluding  vegetables  and  pastry,  was  ordered,  which 
was  well  borne,  to  the  great  surprise  of  the  patient.  A  daily  ablution,  with 
gradually  reduced  water,  accustomed  the  patient  to  the  cold  plunge  (60°),  fol- 
lowed by  friction  and  out-door  exercise.  Having  occasion  to  visit  one  of  his 
patients  in  consultation  a  year  later,  I  found  the  doctor  much  improved  in  flesh  ; 
his  general  health  good,  and  maintained  by  continuing  the  daily  hydrotherapy 
which  I  had  prescribed  for  him  and  by  visiting  his  patients  on  a  bicycle  in  the 


474        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

summer.     He  thinks  he  "  would  have  died  if  he  had  continued  his  former  pro- 
fessor's advice  to  live  on  meat  and  hot  water.  " 

One  of  the  chief  difficulties  in  these  cases  of  nervous  dyspepsia  is 
the  dread  of  infringement  upon  what  they  have  been  led  to  regard  as 
good  dietetic  rules.  The  usual  effect  of  a  test  lavage  (one  of  our  sim- 
plest hydriatric  procedures)  is  marvellous  in  these  cases,  inasmuch  as 
it  enables  us  to  build  up  the  nutrition  and  thus  improve  the  general 
health  upon  which  the  local  disease  seems  to  depend  in  most  cases,  as 
illustrated  in  those  already  cited.  The  doctor' s  case  cited  above  demon- 
strates what  may  be  accomplished  at  the  patient's  home.  I  will  not 
here  repeat  the  methods  of  hydrotherapy  indicated,  save  to  say  that 
ablutions  with  water  at  75°,  reduced  one  degree  every  day,  the  patient 
standing  in  a  little  warm  water,  is  a  good  domestic  measure,  and  may 
be  followed  advantageously  by  daily  cold  affusions  thrown  with  good 
force.  Afterward  institution  treatment,  where  the  temperature, 
pressure,  and  duration  may  be  applied  with  precision,  would,  if  neces- 
sary, be  more  useful  by  reason  of  the  previous  hydriatic  training  of 
the  patient.  In  addition  to  these  general  procedures  I  have  obtained 
great  advantage  from  the  trunk  compress,  the  rationale  of  which  does 
not  require  repetition.  Suffice  it  to  reiterate  that  it  is  a  continuous 
local  stimulant,  producing  cutaneous  hypersemia,  and  that  at  each 
renewal,  three  or  four  times  daily,  the  gentle  shock  arising  from  its 
application  adds  to  the  tonic  effect,  by  first  contracting  the  cutaneous 
vessels  and  under  the  subsequent  reaction  dilating  them. 

In  obstinate  cases  of  dyspepsia  referred  to  me  by  colleagues,  after 
the  trial  of  all  known  remedies,  as  illustrated  by  the  cases  cited,  a 
judicious  water  treatment  had  rarely  failed,  especially  if  the  patient  was 
away  from  home  and  could  be  induced  to  submit  to  a  systematic  course 
of  douches.  Under  the  magic  touch  of  this  flagellation  with  a  solid 
column  of  cold  water  or  the  more  gentle  stinging  spray  of  the  fan 
douche,  these  unhappy  creatures  bloom  forth  into  health  and  content- 
ment. Their  moodiness,  introspection  and  apprehensions  of  evil,  their 
tendency  to  magnify  slight  ailments  into  serious  maladies — all  disap- 
pear like  a  mist  before  the  rising  sun,  when  the  physician  applies  all 
the  resources  of  hygiene,  diet,  and  hydrotherapy  with  judgment  and 
skill,  and  avoids  slipshod  routine. 

The  result  aimed  at  must,  however,  be  clearly  before  the  physician. 
The  peripheral  stimulus  must  be  so  adapted  to  each  case  that  its  effect 
is  conveyed  to  the  central  nervous  system,  with  the  result  of  enhance- 
ment of  the  innervation  of  the  stomach  in  the  general  beneficent 
result.  All  excitation  must  be  avoided ;  while  the  heart  is  driven  to 
better,  more  thorough  work,  it  must  not  be  overstimulated.  The 
result  will  be  a  removal  of  the  plethoric  condition  of  the  abdominal 


DYSPEPSIA.  475 

circulation,  because  the  blood  is  put  into  active  fluxion  by  its  with- 
drawal from  the  interior  to  the  large  cutaneous  vessels.  Thus  the 
stomach  and  liver  are  supplied  with  better  aerated  blood,  their  local 
circulatory  condition  is  enhanced  by  the  invigorated  general  circula- 
tion, and  the  nutritive  conditions  are  improved.  That  this  is  not 
theoretical  deduction  is  daily  proved  by  clinical  results. 

It  is  not  the  writer' s  purpose  to  burden  these  pages  with  clinical 
histories  of  his  own  cases,  except  to  illustrate  the  hydriatic  methods 
adopted  in  their  management,  which  may  be  useful  as  a  guide  to  the 
reader  in  the  practical  application  of  water  in  disease.  Individual 
observations  may  be  fallacious ;  the  enthusiastic  espousal  of  a  thera- 
peutic agent  or  method  may  bias  the  observer.  Therefore  I  propose  to 
present  in  the  interest  of  fairness  the  views  of  others  whose  large 
clinical  material  entitles  their  opinions  to  respectful  consideration. 

In  an  essay  on  "  The  Diagnosis  and  Hydrotherapy  of  Stomach  Dis- 
eases," read  before  the  Balneological  Society  of  Berlin,*  Dr.  Alois 
Strasser,  clinical  assistant  to  the  Allgemeine  Poliklinik,  in  Vienna, 
discusses  the  present  methods  of  diagnosis  in  stomach  diseases  in  a  care- 
ful, conscientious,  and  scientific  manner,  arriving  at  the  same  conclusion 
which  I  had  expressed  in  a  paper  on  "The  Clinical  Aspects  of 
Dyspepsia, "  read  before  the  South  Carolina  Medical  Association  April 
25th,  1895,  that  "  the  number  of  clinical  tests  which  have  been  proposed 
for  the  purpose  of  obtaining  a  reliable  measure  of  the  digestive  capacity 
of  the  stomach  is  bewildering  to  the  general  practitioner.  They  often 
serve  no  useful  purpose,  when  the  treatment  is  to  be  studied  out  and  prac- 
tically applied."  Dr.  Strasser's  review  indicates  a  thorough  mastery, 
not  only  of  all  the  scientific  chemical  methods,  but  also  of  the  practical 
aspect  of  the  subject — the  treatment.  "  Hydrotherapy  may  be  utilized 
with  some  success  in  every  form  of  stomach  disease.  This  is  proved 
by  the  results  of  all  hydrotherapeutic  institutions.  For  instance,  the 
statistics  of  the  institution  at  Kaltenleutgeben  show,  during  the  past 
twenty-five  years,  fourteen  hundred  and  twenty-four  stomach  and 
intestinal  cases  (the  former  in  large  majority,  the  latter  mostly  united 
with  the  former).  Of  these  only  four  per  cent  left  the  institution  with- 
out being  cured.  It  is  true  that  a  large  proportion  of  stomach  cases  are 
of  a  nervous  type,  which  may  favorably  influence  the  statistics ;  still 
we  must  remember  that  nervous  gastric  cases  are  not  sent  at  once  to 
institutions,  but  often  only  after  the  primary  neurotic  disease  becomes 
converted  into  an  anatomical  one. 

"  Nervous  dyspepsia  becomes  changed  to  a  chronic  gastric  catarrh 
and  the  atony  is  transformed  into  a  regular  muscular  insufficiency ; 
secondly,  the  category  of  nervous  cases  contains  many  which,  after 
*  Blatter  fur  klinische  Hydrotherapie,  May,  1896. 


476        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

having  been  treated  in  vain  by  various  medicines,  resort  to  hydro- 
therapy  as  a  last  refuge." 

My  personal  observation  has  led  me  to  the  conclusion  that  flabby 
or  anaemic  dyspeptics,  and  those  of  the  better  nourished  class,  who 
present  psychical  manifestations  or  neurasthenic  symptoms,  are  the 
most  favorable  subjects  for  hydrotherapy.  The  fact  must  not  be  lost 
sight  of  that  the  latter  is  not  a  specific  in  this  malady ;  it  is  only  a 
potent  aid  in  the  hygienic  and  dietetic  management.  Many  cases 
which  fail  under  the  latter  may  improve  if  judicious  hydrotherapy  be 
added. 

CONSTIPATION. 

Among  the  most  trying  manifestations  of  dyspepsia  and  often  with- 
out the  distinct  evidence  of  the  latter,  in  neurasthenics  and  among 
sedentary  people  in  ordinary  health,  a  sluggish  peristalsis  is  often  the 
bane  of  their  lives.  It  is  not  our  province  to  dwell  upon  the  necessity 
of  exercise,  change  of  environment,  diet,  etc. ;  these  are  too  well 
understood.  Prolonged  and  careful  observation  has  convinced  the 
author  that  the  addition  of  some  form  of  hydrotherapy  enhances  the 
value  of  hygienic  and  dietetic  measures,  and  often  succeeds  after  the 
latter  alone  have  failed.  Fleiner  recommends  the  hip  bath  of  two  to 
five  minutes,  temperature  50°  to  68°  F.,  once  or  twice  daily,  and  an 
abdominal  compress  of  50°  F.  at  bedtime.  We  have  obtained  some 
excellent  results  from  these  procedures  and  many  failures.  In  the 
latter  the  jet  douche  of  thirty  pounds  pressure  from  a  one-eighth- 
inch  nozzle,  slowly  played  over  the  region  of  the  colon,  either  at  45° 
or  110°  F.,  has  often  furnished  satisfactory  results.  This  form  of 
hydrotherapeutic  massage  may  be  continued  from  five  to  fifteen  min- 
utes, if  done  slowly,  and  repeated  once  a  day  before  the  usual  time  for 
evacuation.  This  form  of  abdominal  douche  is  highly  commended  by 
Nothnagel  (who  uses  them  cold)  and  Hackel.* 

In  constipation  occurring  in  gouty,  anaemic,  or  otherwise  depreci- 
ated patients,  a  thorough  intestinal  irrigation  with  salt  solution,  ad- 
ministered every  day,  removes  ptomains.  If  followed  by  the  rapid 
introduction  and  outflow  of  eight  ounces  of  water  at  40°,  a  reflex 
stimulation  is  aroused.  It  is  the  author' s  custom  to  use  these  irrigations 
for  a  week  and  omit  them  for  a  week.  He  would  condemn  the  enormous 
colonic  irrigation  which  has  been  furthered  by  the  empirics  as  harmful, 
because  of  the  overdistention  and  consequent  enfeeblement  of  the 
bowels.  Irrigation  provides  for  rapid  outflow,  the  enema  for  retention 
of  the  water  as  long  as  the  patient  can  hold  it.  In  all  cases  of  con- 
stipation tonic  hydriatric  procedures  are  of  as  great  value  as  is  muscular 
exercise,  which  it  may  often  substitute  temporarily  in  feeble  patients. 
*  Deutsche  medicinische  Wochenschrift,  1899,  No.  1. 


CHAPTER  XXVIII. 
INSANITY. 

THE  methodical  application  of  hydrotherapy  in  mental  diseases  is 
of  very  recent  date  in  this  country.  The  author  is  gratified  by  the 
statement  of  asylum  physicians,  quoted  below,  that  he  has  been  suc- 
cessful in  the  propaganda  for  its  systematic  use  in  insane  asylums. 
As  a  general  practitioner,  cases  of  mental  disease  have  not  come  under 
the  author's  observation  in  sufficient  number  to  warrant  reliable  de- 
ductions. He  has  therefore  aimed  in  this  chapter  to  present  the 
views  of  practical  alienists,  men  who  live  and  labor  among  this  un- 
fortunate class.  They  are  most  competent  to  offer  actual  clinical  ob- 
servations, upon  which  alone  hydrotherapy  must  stand  or  fall. 

It  is  a  sad  commentary  on  the  lack  of  interest  displayed  in  hydro- 
therapy  to  note  that,  despite  the  fact  that  a  few  discerning  minds  have 
grasped  the  principles  and  applied  the  technique  of  hydrotherapy  suc- 
cessfully in  insanity,  the  mass  of  alienists  still  seem  to  be  unaware 
that  precision  and  exact  technique  are  the  essentials  of  successful  hy- 
drotherapy in  mental  diseases  as  they  are  in  other  maladies.  In  a 
recent  American  text-book  on  insanity,  the  only  mention  of  this  sub- 
ject is  as  follows :  "  The  use  of  baths  generally  in  insanity  has  been 
highly  commended,  especially  the  Turkish  bath." 

In  striking  contrast  to  the  above  stand  the  following  earnest  and 
well-weighed  comments  of  Dr.  Frederick  Peterson,  professor  of  psy- 
chiatry in  Columbia  University  and  a  practical  alienist  of  high  repute :  * 

"  In  continental  Europe  the  '  water  cure '  has  become  of  late  a  scien- 
tific remedy,  one  recognized  as  of  great  value,  and  everywhere — in 
asylums,  hospitals,  at  health  resorts,  and  in  the  cities — at  the  com- 
mand of  all  physicians  in  private  practice,  are  excellent  means  of 
making  use  of  hydrotherapy  where  it  is  indicated. 

"  I  will  here  enter  into  details  as  to  hydrotherapeutic  measures  only 
in  so  far  as  mental  and  nervous  diseases  are  concerned;  their  mani- 
fold application  in  a  great  variety  of  general  diseases,  such  as  fevers, 
disorders  of  the  stomach  and  intestinal  tract,  affections  of  the  respira- 
tory and  circulatory  organs,  and  the  like,  has  become  fairly  known  in 
America,  particularly  through  the  earnest  propaganda  of  Dr.  Simor 
Baruch,  of  New  York. 

*  American  Journal  of  the  Medical  Sciences,  February,  1893. 


478        THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

"  In  my  tour  of  inspection  of  asylums  for  the  insane  in  Germany, 
Holland,  France,  Belgium,  Italy,  and  Austria,  in  the  winter  of  1886- 
87,  I  was  surprised  to  find  how  universally  hydrotherapy  was  em- 
ployed in  the  treatment  of  certain  conditions  in  insanity,  and  with 
what  excellent  results;  and  in  a  visit  to  the  new  insane  asylum  at 
Athens,  Greece,  in  1892,  I  was  astonished  to  note  how  well  equipped 
a  hydrotherapeutic  establishment  it  possessed,  although  situated  in  a 
country  we  are  disposed  to  consider  somewhat  out  of  the  track  of  mod- 
ern progress. 

"  On  my  return  to  America,  in  1887,  I  put  into  practice,  as  well  as 
means  would  permit,  at  the  Hudson  Kiver  State  Hospital  for  the  In- 
sane, some  of  the  principles  of  hydrotherapy  that  I  had  acquired 
abroad;  but  as  the  facilities  were  quite  inadequate,  my  hydrothera- 
peutic measures  were  limited  to  applications  of  warm  and  cold  baths, 
brief  or  prolonged,  the  wet  pack,  wet  compresses,  and  ice  bags. 
Nevertheless,  I  learned  from  observation  and  experiment  how  much 
(  could  be  accomplished  in  the  treatment  of  insomnia,  congestive  con- 
ditions, states  of  mental  excitement,  restlessness,  and  the  like  by  even 
such  simple  measures,  and  understood  how  much  more  might  be  done 
were  each  asylum  provided  with  means  for  the  methodical,  systematic, 
and  scientific  employment  of  the  '  water  treatment.'  As  it  is,  I  do 
not  know  of  any  asylum  in  America  that  is  supplied  with  anything  be- 
yond the  ordinary  baths  for  purposes  of  cleanliness,  and  one  of  the  objects 
of  this  article  is  to  stimulate  a  more  general  consideration  of  the  value 
of  hydrotherapy  by  asylum  authorities,  with  the  hope  that  it  may  lead 
to  installation  of  the  necessary  apparatus  in  most  of  these  institutions  in 
our  land.  Before  entering  specifically  into  this  subject,  I  wish  to  call 
the  attention  of  asylum  physicians  to  the  adaptability  of  the  rain  bath 
for  the  general  purposes  of  clean liness  among  patients  in  their  institu- 
tions. 

"  In  our  large  asylums,  as  is  well  known,  one  or  at  most  two  station- 
ary bathtubs  are  supplied  for  each  ward.  While  every  precaution  is 
taken  as  regards  cleanliness  as  can  be  taken  by  the  asylum  authorities, 
still  one  is  inclined  to  doubt  the  perfection  of  such  bathing  arrange- 
ments, and  it  seems  tome  that  the  rain-bath  system  could  be  employed 
with  even  more  advantage  in  these  institutions  than  in  the  public  baths 
of  cities.  I  hope  some  of  our  progressive  superintendents  will  initiate 
this  change.  They  will  find  in  New  York  examples  of  the  rain-bath 
system,  recently  introduced,  through  the  able  advocacy  of  Dr.  Baruch, 
at  the  public  bath-houses  at  No.  7  Central  Market  Place,  at  the  Demilt 
Dispensary  (corner  of  23d  Street  and  Second  Avenue),  the  Baron  De 
Hirsch  baths  at  Essex  and  Market  streets,  and  at  the  Juvenile  Asy- 
lum. Another  advantage  of  the  rain  baths  in  asylums  would  be  the 


INSANITY.  479 

prevention  of  injuries  such  as  occur  occasionally  on  putting  excitable 
patients  into  the  tubs,  and  the  impossibility  of  scalding  or  suicide. 
Rare  as  these  accidents  may  be,  they  have  to  be  carefully  guarded 
against  under  present  arrangements. 

11 A  Simple  Hydriatic  Chamber. — This  might  easily  be  provided  in 
each  ward — or,  at  least,  in  one  out  of  five  wards — by  slight  alteration  of 
the  present  bath-rooms.  The  walls  would  require  protection  by  means 
of  a  rubber  lining,  or,  better,  tiles  or  marble,  and  the  floor  should  be 
zinc-lined,  tiled,  cemented,  or  made  of  asphalt.  Several  rain  baths 
should  be  installed.  There  should  be  one  stationary  bathtub.  There 
should  be  several  kinds  of  douches  connected  with  the  hot — and  cold — 
water  pipes,  and  to  this  douche  apparatus  should  be  attached  a  ther- 
mometer and  gauge  for  measuring  the  temperature  and  pressure.  In 
summer  a  small  reservoir  should  be  arranged  (coils  packed  in  ice)  for 
obtaining  cold  water  when  required.  A  hot-air  box  is  very  useful. 
The  equipment  is  complete  when  to  these  are  added  one  or  two  foot 
baths,  a  sitz  bath,  several  cooling  caps  or  ice  caps,  Chapman's  ice  bags, 
and  a  liberal  supply  of  linen  for  wet  packing,  dry  packing,  wet  com- 
presses, and  bandages, 

"  It  is  very  essential  that  such  an  establishment  be  put  in  charge  of 
an  intelligent  nurse,  who  would  learn  under  the  direct  instruction  of 
the  physician  in  charge  how  to  carry  out  properly  every  procedure. 

"  The  room  should  be  capable  of  being  heated  to  such  a  temperature 
as  will  feel  agreeable  to  the  bather  when  undressed.  It  is  needless  to 
say  that  patients  should  not  be  treated  in  a  cold  bath-room.  (See 
page  395,  Hydriatric  Apparatus.  The  author  would  suggest  neuro- 
vascular  training  before  proceeding  to  the  low  temperatures  "  for  tonic 
effects,"  and  higher  temperatures  "to  produce  sleep, "in  the  following 
chapters.) 

"INDICATIONS  AND  METHODS. 

"For  Tonic  and  Refreshing  Effects.—  A  cold  rain  bath  (50°  to  70°), 
the  patient  rubbing  himself  while  in  the  bath,  duration  five  to  ten  sec- 
onds ;  or  the  half -bath  in  a  tub  at  65°  to  75°  F. ,  ten  to  thirty  minutes. 
By  "  half -bath  "  is  meant  only  six  to  eight  inches  of  water  in  the  tub, 
in  which  the  patient  lies  and  splashes  about  and  is  rubbed  by  an  at- 
tendant. The  object  in  both  is  to  get  the  exhilarating  and  stimulating 
effects  of  the  cold,  and  also  the  mechanical  effect  of  the  water  imping- 
ing upon  the  skin.  Such  a  bath  should  be  taken  every  morning. 

"For  Powerful  Tonic,  Revulsive,  and  Derivative  Effects. — The  cold 
douche  increases  reflex  excitability  and  causes  hypersesthesia  of  the 
skin.  It  is  a  powerful  stimulus,  mental  and  physical.  By  means  of 
various  nozzles  it  may  be  ejected  in  the  form  of  a  jet,  a  spray,  a 


480       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

shower,  a  fan,  and  by  alternating  with  hot  and  cold  water  we  have 
what  is  known  as  the  Scotch  douche.  Such  procedures  are  indicated 
in  lethargic  and  hysterical  forms  of  insanity,  where  there  is  a  sluggish- 
ness of  the  intellect,  apathy,  stupor,  catalepsy,  etc.,  and  in  melan- 
cholic cases  and  in  all  cases  in  which  there  are  anaemia,  chlorosis,  or 
gastric  disorders. 

"  To  Produce  Sleep. — The  prolonged  warm  whole  bath  is  indicated. 
Temperature,  70°  to  90°.  Duration,  one-half  to  two  hours.  When 
of  long  duration  the  patient  may  be  suspended  in  a  hammock  made  of 
a  sheet.  Indicated  in  cases  of  melancholia  with  excitement  and  in 
some  maniacal  conditions.  As  a  general  hypnotic  agent,  however,  ap- 
plicable to  all  forms  of  insomnia  among  the  insane,  the  hot  wet  pack 
stands  foremost.  It  is  applied  in  this  way :  A  blanket  nine  by  nine 
feet  is  spread  upon  the  patient's  bed,  and  upon  this  a  sheet,  wrung 
out  dry  after  dipping  in  hot  water,  is  laid.  The  patient  lies  down  upon 
this,  and  the  sheet  is  at  once  evenly  arranged  about  and  pressed  around 
the  whole  body  with  the  exception  of  the  head,  after  which  the  blanket 
is  also  immediately  likewise  closely  adjusted  to  every  part  of  the  pa- 
tient's body.  Other  dry  blankets  may  now  be  added  as  seems  neces- 
sary. The  patient  remains  in  this  an  hour  or  longer;  all  night  if 
asleep." 

(See  page  135  for  reasons  why  the  cold  wet  pack  is  superior  to  the  hot 
wet  pack  for  maintaining  cutaneous  hyperaemia,  which  is  essential.) 

"  Maniacal  Excitement. — In  this  condition  we  all  know  how  impor- 
tant it  is  to  control  motor  excitement  as  much  as  possible  in  order  to 
prevent  the  metabolic  waste  that  progresses  only  too  rapidly  in  many 
cases,  often  leading  to  death  from  exhaustion  in  a  few  days.  Formerly 
we  were  accustomed  to  fasten  the  patient  in  bed  with  a  strait-jacket 
and  dose  with  hyoscyamine  liberally,  and  this  treatment  undoubtedly 
saved  many  lives,  but  the  fastening  in  bed  has  been  to  a  great  extent 
tabooed  of  late  years.  It  is  astonishing  to  note  the  good  effects  of  hy- 
drotherapy  in  many  cases  of  this  kind.  The  measures  to  be  carried 
out  are  those  indicated  for  insomnia.  It  is  not  often  that  patients 
laboring  under  great  excitement  can  be  placed  in  the  warm  bath,  but 
the  wet  pack  is  applicable  in  nearly  every  case.  It  not  only  diminishes 
erethism,  but  often  brings  about  refreshing  sleep,  and  always,  when 
kept  applied,  prevents  metabolic  waste  by  motor  excitement.  I  know 
of  nothing  that  gives  one  better  results  in  such  cases  than  the  wet  pack 
in  conjunction  with  overfeeding  and  occasional  doses  of  hyoscyamine 
or  duboisine  if  needed. 

"  Congestive  Headaches. — These  headaches  are  quite  common  among 
the  insane  and  one  of  the  best  hydriatic  procedures  for  their  relief 
is  a  running-water  cold  foot  bath  every  evening  (twenty  minutes, 

*See  Continuous  Bath. 


IlfSANITY.  481 

60°),  or  the  fan  douche  to  the  feet  (five  minutes,  60°),  is  very  pallia- 
tive. 

"  Hysteria. — For  erethetic  type :  Wet  pack,  60°  to  70°  for  one  hour 
or  more,  followed  by  massage  (Putnam  Jacobi) ;  or  the  rain  bath  at 
75°  to  65°,  for  thirty-five  seconds  daily  at  twenty  pounds  pressure 
(Baruch). 

"  For  depressed  type  :  Cold  affusions  while  standing  in  warm  water, 
or  hot-air  bath,  followed  by  rain  bath  for  thirty  seconds  at  85°,  daily 
reducing  until  60°  is  reached,  this  to  be  followed  by  spray  douche  for 
five  seconds  at  65°,  or  jet  douche  for  three  seconds  at  65°  to  55°.  Re- 
duce douche  gradually  to  50°  or  less,  increasing  pressure  from  two 
pounds  to  thirty  (Baruch). 

"  Constipation. — In  the  atonic  condition  of  the  intestines  in  most 
cases  of  melancholia  and  in  some  other  forms  of  insanity,  a  powerful 
stimulus  to  peristalsis  will  be  found  in  pouring  water  over  the  abdo- 
men when  the  patient  is  in  a  tonic  half -bath  of  low  temperature." 

The  author  is  convinced  that  Dr.  Peterson's  earnest  and  able  plea, 
only  a  portion  of  which  is  here  reproduced,  aroused  the  attention  of 
asylum  physicians  to  the  subject  of  hydrotherapy.  For  since  its  pub- 
lication he  has  received  frequent  inquiries  on  the  subject  from  such 
physicians,  many  of  whom  have  attended  his  instruction  and  had 
nurses  trained  at  his  clinics  and  have  installed  the  douche  apparatus 
devised  by  him  for  the  exact  application  of  water. 

The  following  clinical  evidence  may  be  of  interest  to  alienists  who 
are  not  already  familiar  with  this  enormous  therapeutic  resource  in 
these  often  hopeless  cases. 

The  report  of  the  Government  Hospital  for  the  Insane  (in  Wash- 
ington), for  1898,  contains  a  special  section  devoted  to  the  results  of 
hydrotherapy.  Dr.  Godding  states :  "  The  hydrotherapeutic  work  has 
been  continued  and  its  field  considerably  extended,  with  very  encour- 
aging results.  The  apparatus  in  use  is  essentially  that  of  Dr.  S. 
Baruch,  of  New  York  City.  I  have  requested  Dr.  Foster,  who  has 
charge  of  the  hydrotherapeutic  work,  to  prepare  a  more  extended  re- 
port. I  think  his  facts  bear  out  his  conclusions." 

General  Paralysis. —  Dr.  Foster*  furnishes  several  abbreviated  histo- 
ries of  cases  which  received  "hydric  treatment,"  and  summarizes  the 
favorable  report  (page  76)  as  follows : 

"  Is  it  likely  that  such  a  showing  could  be  made  in  any  twenty-one 
untreated  cases,  taken  at  all  stages  of  the  disease?  Under  like  circum- 
stances, can  six  arrests  at  one  time,  with  a  duration  extending  from 

*  Dr.  Foster  was  among  the  earliest  asylum  physicians  to  seek  personal  in- 
struction in  hydrotherapy  from  the  author.  To  his  able  clinical  demonstration 
is  the  phenomenally  rapid  adoption  of  hydrotherapy  in  asylum  practice  to  be 
traced. 

31 


482        THE   PRINCIPLES  AND   PRACTICE   OF  HYDRO-THERAPY. 

four  months  to  three  years,  be  shown?  If  not,  some  value  must  be 
conceded  to  this  treatment. 

"  It  should  be  fully  understood  that  reliance  is  not  placed  upon  hy- 
drotherapy  alone  in  the  treatment  of  these  cases.  On  the  contrary, 
every  available  means  that  holds  out  the  promise  of  benefit  to  the  indi- 
vidual case  is  strenuously  employed.  It  is  only  claimed  for  hydro- 
therapy  that  it  is  the  chief  remedy;  that  in  some  form  it  is  applicable 
and  of  benefit  to  all,  and  that  without  its  aid  the  other  measures  em- 
ployed could  not  have  produced  equally  favorable  results. 

"  We  should  also  have  in  mind  some  standard  for  gauging  results, 
which  will  vary  with  different  cases  depending  upon  the  stage  of  the 
disease,  and  especially  upon  the  time  during  which  degenerative 
changes  have  progressed. 

"  If  we  could  examine  the  brain  of  any  paretic  in  whom  the  disease 
had  existed,  say  from  three  to  five  years,  we  should  undoubtedly  find 
marked  sclerotic  and  atrophic  changes,  the  attendants  upon  cell  de- 
generation. If  the  disease  should  be  permanently  arrested  in  any  such 
case,  there  must  remain  more  or  less  permanent  loss  of  cerebral  func- 
tion; that  is,  there  will  be  more  or  less  secondary  dementia,  which 
will  be  permanent ;  as  is  true  of  any  form  of  chronic  insanity  which 
has  been,  as  we  say,  'cured.' 

"In  the  case  of  J.  B.  McD.,  with  a  duration  of  one  and  one-half 
years,  the  permanent  loss  is  scarcely  appreciable.  In  that  of  W.  K., 
Jr.,  of  seven  years'  duration,  the  limit  of  improvement  has  probably 
been  nearly  reached.  In  G.  M.,  five  years'  duration,  improvement 
has  already  exceeded  what  one  would  expect,  and  still  it  slowly  con- 
tinues. In  F.  M.  the  period  of  disease  was  short,  and  but  little  resid- 
ual impairment  is  now  noticeable. 

"  If  either  or  all  these  arrests  should  prove  to  be  permanent  and  the 
term  'cured'  applied  to  it,  the  term  would  evidently  have  a  sorne- 
Avhat  different  value  in  each  case.  Whatever  the  term  used,  it  can 
only  mean  arrest,  with  regeneration  of  such  neurons  as  have  not  reached 
the  point  of  hopeless  degeneration. 

"  In  addition  to  the  cell  degeneration  there  remain  also  vascular 
changes  which  are  permanent,  and,  according  to  their  degree,  a  source 
of  danger  in  arrested  cases,  should  conditions  arise  involving  either 
toxic  or  congestive  strain. 

"  In  describing  these  cases  of  epilepsy  and  paresis  I  have  avoided 
minuteness  of  detail,  lest  it  should  become  too  tedious.  It  is  hoped 
that  sufficient  salient  points  have  been  stated  to  subserve  the  desired 
purpose  of  comparison,  in  order  to  estimate  the  results  of  treatment." 

In  an  able  essay  on  "Hydric  Treatment  of  the  Insane,"  Dr.  Foster 
writes :  "  It  may  be  added  in  this  connection  that  there  is  no  better 


INSANITY.  483 

means  known  to  influence  the  early  intercellular  nutritional  changes  of 
insanity,  whether  the  latter  be  the  effect  of  functional  strain  or  over- 
work or  toxic  influences.  In  the  former  cases  the  nutritional  and 
tonic  effects  are  invoked,  eliminative  processes  being  conjoined  in  the 
latter. 

"  But  what  should  be  the  method  of  procedure  on  the  part  of  those 
not  already  practically  familiar  with  the  subject,  who  feel  inclined  to 
test  its  value?  The  answer  is  emphatic :  To  first  of  all  make  ade- 
quate preparation  by  studying  the  best  literature  of  the  subject,  and 
by  becoming  thoroughly  familiar  with  the  physiological  problems  in- 
volved and  with  approved  clinical  methods.  Anything  less  will  result 
in  failures,  disappointments,  and  undeserved  discredit  of  the  method. 
Do  not  rely  upon  any  short  disquisition  of  a  score  of  pages,  for  such 
must  prove  inadequate  and  misleading  if  made  the  chief  reliance. 
After  this  preparation  it  is  not  necessary  to  wait  until  an  elaborate 
plant  is  installed,  for  while  you  are  using  such  appliances  as  are  ready 
to  your  hand,  or  can  readily  be  devised,  the  principles  and  procedures 
already  studied  can  be  carried  into  effect  and  submitted  to  the  proof 
of  experience.  Study  principles !  If  there  were  nothing  more  to  it 
than  the  application  of  certain  empirical  methods,  it  might  as  well  be 
left  to  the  empirics  themselves,  with  their  mingled  successes  and  fail- 
ures, both  alike  inexplicable  to  them. 

"  At  the  present  time  it  can  perhaps  fairly  be  said  that  the  user  is 
on  trial  even  more  than  the  method,  since  the  latter  is  already  sup- 
ported by  decisive  testimony.  If  it  is  capable  of  good  it  is  a)so  capa- 
ble of  harm,  though  no  remedy  is  safer  in  proper  hands.  If  it  is  a 
flexible  instrument,  and  capable  of  many  adaptations,  the  more  need 
of  care  in  securing  the  proper  adaptation  to  the  exigency  at  hand. 

"  Probably  the  most  satisfactory  series  of  cases  of  all  that  have 
been  brought  under  the  treatment  here  consists  of  nine  soldiers  or 
sailors  of  the  war  with  Spain,  whose  treatment  began  subsequently  to 
the  finishing  of  the  report,  or  since  October  1st,  1898. 

"  They  had  suffered  from  the  physical  and  emotional  strain  inciden- 
tal to  the  unaccustomed  hardships  of  army  life  in  the  hot  climate  of 
Cuba,  etc.  The  first  case  is  so  recent  that  it  can  only  be  cited  as 
showing  improvement,  which  may  prove  only  temporary.  !N"o  other 
treatment  is  being  employed. 

"  The  remaining  eight  are  cases  of  conf usional  type  with  extreme 
mental  weakness,  associated  in  all  but  two  cases  with  marked  physical 
depression.  In  the  two  cases  not  exhibiting  marked  physical  weak- 
ness the  condition  was  stuporous.  They  had  already  been  under  treat- 
ment for  periods  varying  from  two  to  six  months,  and  only  one  was 
showing  tendency  to  improvement  when  brought  under  hydric  treat- 


484       THE  PRINCIPLES  AND  PRACTICE   OF   HYDROTHERAPY. 

ment.  All  have  improved.  Three  have  recovered  and  have  been  dis- 
charged. Two  more  have  nearly  recovered  normal  mental  tone  and 
will  soon  be  discharged.  The  remaining  four  are  making  such  steady 
progress  as  indicates  recovery  in  the  near  future.  In  two  of  the  latter, 
improvement  was  very  slight  during  the  first  four  and  six  weeks  re- 
spectively, after  which  physical  and  mental  gain  have  gone  on  steadily 
together.  The  rapidity  of  improvement  of  the  majority  of  these  sta- 
tionary cases,  as  soon  as  brought  under  treatment,  was  almost  marvel- 
lous, and  seems  to  mark  this  type  of  mental  disease  as  especially  suit- 
able for  the  treatment.  That  the  breakdown  was  sudden,  under  severe 
stress,  would  perhaps  probably  be  regarded  as  a  favorable  feature; 
but  it  should  still  be  borne  in  mind  that  they  had  nearly  all  reached  a 
period  when  improvement,  if  there  had  been  any,  had  ceased."* 

From  an  essay  read  before  the  American  Medico-Psychological  As- 
sociation, at  Quebec,  in  June,  1902,  the  following  citations  are  culled 
for  the  purpose  of  adding  the  evidence  of  another  active  clinical  alien- 
ist. After  courteously  referring  to  the  author's  labor  for  the  develop- 
ment of  hydrotherapy  in  this  country,  Dr.  Dent  writes : 

"  I  am  personally  indebted  to  him  for  the  privilege  accorded  me 
and  my  staff  in  permitting  us  to  visit  his  institution  and  study  his 
methods.  For  several  years  past  the  bathtub  has  given  place  to  the 
rain  bath,  or  spray  douche  bath,  which  is  at  present  used  exclusively 
throughout  the  institution,  except  in  the  rare  cases  in  which  the  port- 
able tub  is  found  to  be  more  suitable.  Like  all  innovations  this  change 
at  first  was  opposed  alike  by  patients  and  nurses,  but  with  education 
the  dislike  was  gradually  overcome  and  the  baths  one  by  one  replaced 
the  tubs.  So  much  in  favor  are  the  baths  at  present  that  an  attempt 
to  resort  to  the  tub  would  meet  with  decided  objections  on  the  part  of 
the  patients  and  nurses. 

"  The  lavatories  in  the  wards  of  our  hospital  are  e&ch  provided  with 
a  gauge  on  the  bathing  apparatus,  whereby  the  temperature  and  press- 
ure of  the  water  can  be  regulated  at  will,  so  that  it  is  possible  to  ad- 
minister with  a  considerable  degree  of  accuracy  the  Scotch  douche,  jet 
douche,  rain  and  needle  bath.  In  order  to  arrive  at  some  definite  con- 
clusion as  to  the  value  of  water  as  a  therapeutic  agent  in  the  treatment 
of  insanity,  we  have  for  several  years  made  careful  observations  on 
patients  receiving  treatment  with  the  warm  and  cold  full  baths,  warm 
and  cold  packs,  sitz  baths,  ice  packs,  Scotch  douches,  needle  baths 
and  drip  sheet  baths  in  conjunction  with  the  hot  cabinet. 

"  The  hot-air  cabinet  in  our  hands  has  proven  to  be  a  valuable  agent 
in  relieving  pain  without  the  depressive  effects  common  to  hypnotics 
and  sedatives.  It  stimulates  metabolism,  promotes  absorption,  and  is 

*  American  Journal  of  Insanity,  vol.  lv.,  November  4th,  1899,  p.  643. 


INSANITY.  485 

unquestionably  the  most  valuable  eliminative  agent  we  possess,  and 
when  properly  used  posseses  a  sedative  action  on  the  nervous  system 
obtained  by  no  other  remedy.  >  .  . 

In  adopting  hydriatic  measures,  the  exact  physiologic  and  patho- 
logic conditions  present  must  be  recognized  and  so  influenced  as  to 
bring  about  the  best  results.  Patients  differ  widely  in  their  behavior 
under  treatment,  and  for  this  reason  every  case  requires  careful  physi- 
ologic study  to  determine  the  best  course  to  pursue.  All  authorities 
insist  upon  a,  careful  technique,  and  by  this  alone  can  the  best  results 
be  obtained.  In  many  instances  harm  will  result  when  a  prescription 
is  indifferently  carried  out. 

"  It  would  be  an  unwarranted  consumption  of  your  time  to  review 
the  general  laws  applicable  to  hydrotherapy,  inasnmch  as  they  are 
dealt  with  in  the  text-books  and  are  familiar  to  you  all.  The  follow- 
ing clinical  histories  of  three  cases  are  selected  from  a  number  treated, 
for  the  purpose  of  illustration  :* 

"L.  H ,  age  18,  single;  occupation,  factory  operator ;  heredity  denied; 

assigned  causes  ;  remote,  environment ;  exciting,  anaemia.  Duration  of  present 
attack,  three  weeks  ;  diagnosis,  melancholia  acuta  agitata.  Admitted  to  the  hos- 
pital February  20th,  1901,  with  the  following  history  obtained  from  her  mother  : 

"  Until  two  years  previously  the  patient  had  always  enjoyed  excellent  health, 
and  was  of  a  sanguine  temperament.  From  the  age  of  twelve  she  had  been  con- 
stantly employed  in  a  candy  factory,  and  usually  in  a  room  where  the  tempera- 
ture was  very  high.  For  the  past  two  years,  the  mother  had  noticed  that  her 
daughter  had  been  failing  physically,  and  that  during  this  time  she  had  men- 
struated only  once  or  twice.  One  month  before  admission  the  patient,  who  had 
always  been  bright  and  vivacious,  became  morose,  suspicious,  irritable,  and 
suffered  from  insomnia.  A  few  days  prior  to  coming  to  the  hospital,  she  had 
developed  well-marked  delusions  of  fear  and  persecution,  with  auditory  and 
visual  hallucinations.  She  became  so  frenzied  and  agitated  that  she  could  not 
be  cared  for  at  home. 

"  On  admission  to  the  ward,  the  patient  was  in  a  most  agitated  and  disturbed 
condition,  constantly  pulling  at  her  hair  and  attempting  to  strike  herself  against 
the  stretcher,  moaning  and  crying  in  a  most  pitiful  manner ;  she  had  active  and 
painful  auditory  and  visual  hallucinations,  with  delusions  of  fear. 

"  Physical  examination  of  the  patient  showed  a  poorly  nourished,  anaemic  girl ; 
rectal  temperature,  98.3°;  pulse,  130;  respiration,  21,  very  shallow ;  skin  cold 
and  clammy  ;  mucous  membranes  almost  bloodless  ;  heart  sounds  feeble  ;  anasmic 
murmurs  heard  over  the  vessels ;  sordes  on  teeth  and  lips,  tongue  badly  coated, 
breath  foul ;  marked  cutaneous  hyperaesthesia,  which  appeared  to  be  general ; 
pelvic  organs  normal,  but  undeveloped. 

*  The  reader  is  urged  to  peruse  carefully  all  histories  in  order  that  he  may 
learn  to  adapt  the  varying  procedures  to  analogous  manifestations,  as  shown 
by  the  marked  flexibility  of  hydrotherapy  as  distinguished  from  drugs.  Tliis  is 
the  author's  warrant  for  devoting  so  much  space  to  case  histories,  which  under 
drug  management  have  become  a  b6te  noir.  A  successful  home  treatment  may 
often  thus  prevent  resort  to  the  asylum. 


486        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

"  She  was  put  to  bed  and  given  a  large  simple  enema  at  a  temperature  of  100° 
F.  The  stomach  was  irrigated  with  sterilized  water  at  a  temperature  of  107°  F. , 
and  a  small  quantity  of  peptonized  beef  juice  administered  through  the  stomach 
tube,  as  patient  refused  nourishment. 

"She  continued  in  a  most  agitated  condition,  and  at  6  P.M.  became  wildly 
excited,  constantly  removing  her  clothing,  pulling  at  her  hair,  jumping  out  of 
bed,  and  screaming  at  the  top  of  her  voice  that  she  was  being  burned  up,  etc. 

"  She  was  ordered  a  warm  wet  pack,  the  sheets  being  saturated  with  water  at 
a  temperature  of  112°  F.,  and  covered  over  snugly  with  several  woollen  blankets ; 
an  ice-cap  was  applied  to  the  head  and  a  hot-water  bottle  to  the  feet.  In  about 
one  hour  the  skin  became  active  and  the  patient  commenced  to  take  considerable 
quantities  of  water  voluntarily.  She  gradually  became  quiet,  and  at  the  expira- 
tion of  three  hours  she  was  removed  from  the  pack  and  given  an  alcohol  bath, 
followed  by  light  massage.  She  continued  quiet  and  slept  well  during  the 
night.  In  the  morning  she  again  became  very  much  excited  and  the  pack  was 
again  applied  for  three  hours,  the  patient  offering  less  resistance  to  its  applica- 
tion than  before,  and  soon  falling  asleep.  Warm  packs  were  continued  during 
the  first  week  of  the  patient's  stay  in  the  hospital,  being  employed  about  twice 
in  twenty-four  hours  for  three  hours  at  a  time.  The  patient's  sleep  became 
much  better,  the  large  quantities  of  water  taken  during  the  application  of  the 
pack  promoting  diuresis  and  a  free  movement  of  the  bowels.  The  toxic  mani- 
festations gradually  disappeared,  and  the  motor  and  mental  symptoms  also 
subsided. 

"At  the  end  of  the  first  week  the  auditory  and  visual  hallucinations  had  van- 
ished ;  the  cutaneous  disturbances  were  less  marked  and  the  warm  packs  were 
discontinued  on  account  of  her  improved  condition.  She  was  then  placed  upon 
general  tonic  treatment.  This  was  continued  for  about  two  weeks,  when  it  was 
found  necessary  to  discontinue  it  as  the  stomach  became  irritable,  and  the  patient 
was  then  not  able  to  retain  medicine  or  nourishment.  Her  sleep  became  rest- 
less, and  there  was  a  renewal  of  her  former  mental  symptoms.  At  the  same 
time  she  developed  a  large  number  of  small  but  painful  furuncles,  which  ap- 
peared on  the  scalp,  back,  and  buttocks.  She  was  then  placed  on  the  following 
treatment : 

"  A  hot-air  bath  at  a  temperature  of  180°  F.  was  given  for  ten  minutes  daily, 
with  an  ice-cap  to  the  head,  in  order  to  produce  hypersemia  of  the  superficial 
blood-vessels;  at  the  expiration  of  this  time,  she  was  immediately  taken  from 
the  hot-air  cabinet  and  given  a  needle  bath  at  a  temperature  of  60°  F.  at  fifteen 
pounds  pressure  for  one  minute.  This  was  followed  by  light  massage. 

"  At  the  end  of  the  first  week  of  this  treatment,  she  commenced  to  show  marked 
improvement ;  the  skin  became  more  active,  the  furuncles  disappearing ;  the 
sleep  became  quiet  and  restful,  and  the  hallucinations  subsided  The  appetite 
was  very  much  improved,  and  the  special  peptonized  diet  was  discontinued  and 
the  ordinary  infirmary  food  substituted. 

"At  the  end  of  the  third  week  of  this  treatment,  she  was  again  placed  on  iron 
and  vegetable  tonic,  and  the  Scotch  douche,  at  a  temperature  of  100°  to  59°  F., 
and  a  pressure  of  twenty-five  pounds  daily,  was  substituted  for  the  needle  bath. 
This  was  continued  for  three  weeks,  her  mental  and  physical  condition  gradu- 
ally improving  so  that  at  the  end  of  this  time  all  treatment  was  discontinued, 
and  she  was  transferred  to  the  convalescent  ward,  from  which  she  was  discharged 
June  15th,  1901,  as  recovered,  having  gained  twenty-five  pounds  during  her 
entire  stay  in  the  hospital. 


INSANITY.  487 

"  K.  B ,  aged  20,  married ;  housewife ;  number  of  children,  one ;  age  of 

child,  three  months ;  primipara ;  no  heredity ;  assigned  causes,  remote,  family 
trouble  ;  exciting,  childbirth.  Duration  of  attack,  three  months.  Admitted  to 
the  hospital,  November  29th,  1901,  with  the  following  history  obtained  from  her 
mother : 

"The  patient  had  always  enjoyed  excellent  health  until  the  time  of  her  con- 
finement, three  months  prior  to  her  admission  to  the  hospital.  The  labor  was 
very  tedious  and  difficult.  Soon  after  the  birth  of  her  child  she  became  de- 
pressed and  irritable,  and  refused  to  recognize  her  baby,  relatives,  or  friends. 
She  soon  became  very  suspicious  and  refused  to  take  nourishment,  saying  that 
her  food  was  poisoned,  lying  in  bed  in  a  most  listless  manner,  apparently  mani- 
festing no  interest  in  her  condition  or  surroundings.  She  gradually  became 
worse,  and  finally  was  so  helpless  that  it  became  necessary  to  remove  her  to  the 
hospital. 

"  On  admission  the  patient  was  very  dull,  depressed,  and  refused  to  speak. 
If  persistently  questioned,  she  would  make  a  feeble  effort  to  speak,  but  appar- 
ently was  too  confused  to  collect  herself  sufficiently  to  answer  questions.  The 
tongue  was  coated,  the  breath  foul ;  there  were  sordes  on  the  teeth ;  the  skin 
was  cold  and  inactive,  the  body  was  fairly  well  nourished ;  anaemia  not  pro- 
nounced ;  heart  and  lungs  normal.  Pelvic  organs  normal,  with  the  exception 
of  some  slight  enlargement  of  the  uterus ;  general  cutaneous  anaesthesia  present. 
She  refused  food  and  medication.  The  stomach  was  irrigated  and  nourishment 
administered  from  a  feeding-cup.  Sleep  apparently  excessive. 

"  The  patient  after  being  put  to  bed  remained  in  a  stuporous  and  semicata- 
leptic  condition,  apparently  sleeping  the  greater  part  of  the  time,  and  it  was 
with  difficulty  that  she  could  be  aroused  sufficiently  to  take  nourishment  from  a 
feeding-cup.  On  the  second  day  after  her  admission  to  the  hospital  she  wao 
placed  on  the  following  treatment : 

"She  was  given  a  hot-air  bath  at  a  temperature  of  180°  F.  for  ten  minutes, 
after  which  the  jet  douche  was  applied  at  a  temperature  of  50"  F. ,  at  a  pressure 
of  twenty-five  pounds,  for  one  minute.  This  was  followed  by  light  massage 
and  continued  daily.  During  the  first  week  the  patient  showed  no  apparent 
mental  improvement.  There  was,  however,  an  improvement  in  her  general  cir- 
culation ;  the  skin  became  more  active  and  the  secretions  of  the  body  increased. 
During  the  second  week  she  became  less  stuporous,  and  manifested  some  mental 
improvement  and  more  motor  activity,  at  times  offering  some  slight  resistance 
to  the  jet  douche. 

"At  the  end  of  the  third  week  the  Scotch  douche,  at  a  temperature  of  110°  to 
59°  F. ,  for  two  minutes,  at  a  pressure  of  twenty-five  pounds,  was  substituted 
for  the  jet  douche.  The  patient  continued  to  show  mental  and  physical  im- 
provement. The  Scotch  douche  was  continued  daily  for  three  weeks,  and  her 
mental  and  physical  condition  continued  to  improve,  so  that  at  the  end  of  this 
time  all  treatment  was  discontinued,  and  she  was  allowed  out  of  bed. 

"  Unfortunately,  about  this  time  she  developed  diphtheria,  which  detained 
her  in  the  hospital  for  several  weeks  longer  than  would  have  been  necessary  if 
she  had  not  contracted  this  disease.  She  was  discharged  March  25th,  1902,  as 
recovered.  Diagnosis,  acute  melancholia  with  stupor.  Patient  gained  about 
thirty  pounds  in  weight,  and  no  special  medication  was  used  in  this  case,  except 
antitoxin  for  the  diphtheria. 

"R.  B ,  age  30 ;  married  ;  Russian  ;  tailoress  ;  number  of  children,  three  ; 


488        THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

assigned  causes,  remote,  environment;  exciting,  lactation.  Duration  of  attack 
prior  to  admission,  one  week  ;  diagnosis,  mania  acuta  with  delirium.  Admitted 
to  the  hospital  April  3d,  1902,  with  the  following  history  from  her  husband  : 

"  The  patient  had  always  been  strong  and  healthy  ;  one  year  previously  she 
had  been  confined  and  since  that  time  had  been  nursing  her  child,  at  the  same 
time  performing  her  household  duties,  and,  in  addition,  assisting  him  in  his 
business  as  a  tailor.  She  had  always  been  of  a  sanguine  temperament.  Three 
days  prior  to  her  removal  from  her  home  she  commenced  to  act  strangely,  shouted 
and  screamed  at  the  top  of  her  voice  in  a  most  incoherent  manner,  and  nothing 
of  an  intelligent  nature  could  be  obtained  from  her.  She  assaulted  all  who 
came  near  her,  and  was  especially  resentful  toward  her  children.  She  became 
so  violent  that  it  was  necessary  to  call  in  the  police  and  have  her  removed.  The 
patient  was  received  into  the  hospital  on  a  stretcher ;  she  was  under  the  influ- 
ence of  a  powerful  sedative  ;  the  pupils  were  widely  dilated  ;  there  were  sordes 
on  the  teeth  and  lips;  the  tongue  was  coated  and  other  evidences  of  intestinal 
toxaemia  were  noted.  The  vessels  of  the  ocular  conjunctive  were  intensely  con- 
gested ;  the  pupils  reacted  very  slowly  to  light  and  accommodation.  The 
patellar  reflexes  were  exaggerated  and  considerable  cutaneous  hypersesthesia 
was  present.  Examination  of  the  lungs  showed  a  subacute  bronchitis  of  the 
left  lung  ;  the  skin  was  hot,  dry,  and  inactive  ;  the  body  was  fairly  well  nour- 
ished and  covered  with  large  contusions  and  bruises.  The  patient  was  constantly 
throwing  her  arms  and  limbs  about  in  a  restless  manner  and  rolling  her  head 
from  side  to  side.  She  was  placed  in  bed,  given  a  large  simple  enema  at  tem- 
perature of  100°  F. ,  and  later  received  a  small  amount  of  peptonized  beef  juice 
through  the  stomach  tube.  The  stomach  was  irrigated  with  sterilized  water  at 
a  temperature  of  107°  F.,  and  found  to  contain  only  a  small  amount  of  foul  - 
smelling  mucus,  mixed  with  detritus.  Soon  after  the  patient's  stomach  had 
been  irrigated  she  became  very  maniacal,  and  showed  evidences  of  grave  de- 
lirium ;  most  active  auditory  hallucinations  were  present ;  the  temperature  was 
102.8°,  the  pulse  rate  120,  respirations  20.  She  was  placed  in  a  sitz  bath  at  a 
temperature  of  100°  F. ,  gradually  increased  to  112° ;  the  ice-cap  and  cold  band- 
ages were  applied  to  the  head  and  neck.  Local  massage  was  used  about  the 
pelvis  and  abdomen  while  the  patient  was  in  the  bath.  She  remained  in  the 
sitz  bath  about  twenty  minutes,  and  during  the  time  drank  a  considerable  quan- 
tity of  water.  The  evidences  of  cerebral  congestion  became  less  marked.  The 
patient  was  removed  from  the  bath  and  was  considerably  quieter,  although  she 
still  remained  in  a  delirious  condition.  Six  hours  later  she  again  became  very 
noisy,  violent,  and  most  difficult  to  control.  She  was  placed  in  a  hot,  full  bath, 
temperature  100°,  gradually  increased  to  112°.  At  the  end  of  one  hour  her  pulse 
became  soft  and  rapid,  and  as  she  showed  evidences  of  exhaustion,  she  was  re- 
moved from  the  bath,  given  a  stimulant,  and  placed  in  a  number  of  warm 
woollen  blankets  in  order  to  continue  the  perspiration.  She  remained  in  the 
dry  pack  for  about  two  hours,  after  which  she  became  quiet  and  slept  soundly 
for  several  hours  ;  the  bowels  and  kidneys  acted  freely.  On  the  morning  of  the 
second  day  after  admission  to  the  hospital  she  again  became  very  noisy  and 
maniacal,  but  the  delirium  was  not  so  marked.  The  hot,  full  bath  was  again 
repeated  at  a  temperature  of  100°,  gradually  increased  to  111°  F.  After  remain- 
ing in  the  bath  for  one  hour  she  became  quiet.  These  full  baths  were  continued 
for  three  days,  the  patient  receiving  on  an  average  four  baths  in  twenty- four 
hours.  On  the  morning  of  April  6th,  the  third  day  after  her  admission  to  the 
hospital,  the  patient  was  very  much  quieter  and  her  delirium  had  subsided, 
although  the  hallucinations  of  hearing  continued  active.  On  April  7th  she  de- 


INSANITY.  489 

veloped  several  abscesses  in  the  right  axilla  and  arm.  These  were  opened  and 
irrigated,  but  on  account  of  her  disturbed  condition,  dressings  could  not  be  kept 
in  place.  The  abscesses  were  irrigated  twice  daily.  Her  maniacal  symptoms 
continued  until  April  20th.  During  this  time,  she  received  a  hot  full  bath  at 
bedtime,  which  kept  her  fairly  quiet  during  the  night  and  day.  Her  secretions 
gradually  increased  in  quantity,  the  bowels  became  regular  and  the  skin  active, 
all  the  toxic  symptoms  subsiding  on  the  second  day  after  her  admission  to  the 
hospital.  By  April  24th  all  of  the  mental  symptoms  had  disappeared,  and  she 
was  transferred  to  the  convalescent  ward.  She  gained  about  twenty  pounds  in 
weight :  was  discharged  June  2d  as  recovered,  and  in  a  most  excellent  condition 
physically  and  mentally. 

"  While  I  cannot  claim,  and  do  not  pretend  to  offer,  any  new  obser- 
vations on  the  application  of  water  as  a  therapeutic  agent,  the  results 
I  have  obtained  have  been  most  gratifying  and  confirm  those  of  many 
prominent  authorities  on  this  subject,  and  those  obtained  in  other  hos- 
pitals. I  find  that  when  water  is  properly  applied  in  the  form  of  packs 
and  hot  and  warm  full  baths,  it  acts  as  a  hypnotic  and  sedative,  and 
is  of  great  value  when  it  is  imprudent  to  administer  drugs.  As  an 
eliminative  it  is  of  exceptional  value.  I  find  that  after  a  few  baths 
have  been  administered,  there  is  invariably  an  increase  in  the  quantity 
of  urine  and  a  marked  increase  in  its  solid  constituents ;  that  the  large 
quantities  of  water  the  patient  takes,  during  the  period  spent  in  the 
packs  and  the  hot  full  baths,  promote  free  diuresis  and  assist  the  dia- 
phoresis ;  that  the  application  of  water  for  its  tonic  effect  in  the  form 
of  sprays,  douches,  etc.,  under  hydrostatic  pressure  induces  glandular 
action  by  its  tonic  effect  on  the  general  cutaneous  circulation.  Further- 
more, I  believe  that  the  assimilation  of  iron  and  other  alteratives  is 
promoted  by  these  tonic  baths. 

"  I  know  of  no  condition,  except  advanced  pregnancy,  pleurisy,  or 
when  the  patient  is  practically  moribund,  in  which  some  form  of  hy- 
drotherapy  cannot  safely  be  administered.  Of  course  we  must  recog- 
nize the  fact  that  there  is  some  risk  of  serious  exhaustion  in  the  warm 
packs  and  in  the  warm  and  hot  full  baths,  but  a  nurse  who  is  skilled 
in  the  application  of  these  baths  can  easily  detect  the  danger  signals 
and  remove  the  patient  before  any  serious  consequences  have  resulted. 
I  have  yet  to  meet  with  any  fatal  or  serious  result,  although,  in  this 
hospital,  thousands  of  packs  and  baths  have  been  given.  Of  course 
we  meet  with  more  or  less  opposition  on  the  part  of  the  patient  to  the 
administration  of  these  baths.  I  find,  however,  that  it  is  seldom,  if 
the  patient  be  properly  handled,  that  the  baths  cannot  be  given.  If 
the  patient  is  resisting  and  suspicious,  she  is  allowed  to  see  the  other 
patients  receive  their  treatment,  and  in  her  own  case  the  first  proced- 
ures are  made  as  mild  as  possible.  The  most  resisting  and  suspicious 
patient,  after  she  has  received  one  or  two  treatments,  usually  submits 


490       THE  PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

quietly  and  apparently  enjoys  them.  It  is  ray  custom  to  have  the 
baths  administered  between  the  hours  of  10 :30  A.M.  and  midday,  and 
between  3:30  and  5:30  P.M.,  since  the  stomach  is  comparatively  free 
from  food  at  these  times. 

"  In  conclusion  let  me  urge  that  more  attention  and  consideration  be 
accorded  the  therapeutic  use  of  water  in  the  hospitals  under  our  charge. 
/  know  of  no  other  place  where  the  principles  upon  which  its  action  is 
based  can  be  better  studied,  as  we  have  every  opportunity  for  its  syste- 
matic, persistent,  and  scientific  application."  * 

The  subjoined  clinical  summary  from  another  great  hospital  may 
be  cited  as  trustworthy  evidence  of  results  obtained  from  hydrotherapy 
in  the  management  of  the  insane,  in  this  country. 

"DANVERS  INSANE  HOSPITAL, 
HAWTHORNE,  MASS.,  February  28th,  1903. 

"  DEAR  DR.  BARUCH  : — For  the  past  four  years,  I  have  had  consider- 
able experience  in  the  application  of  hydriatic  procedures  among  the 
insane,  and  am  convinced  that  in  hydrotherapy  the  alienist  finds  one 
of  the  most  effective  means  in  treatment  of  the  class  of  patients  com- 
mitted to  a  public  insane  hospital ;  and  I  will  give  you  such  impres- 
sions as  I  have  formed,  based  upon  experiences  at  this  hospital. 

"A.  As  a  Hypnotic. — The  measures  adopted  for  this  purpose 
have  been  the  warm  full  bath  and  the  wet  pack.  In  administering 
these  procedures  to  the  insane,  careful  selection  must  be  made  for  the 
individual  cases.  It  is  obvious  that  a  struggling,  maniacal  patient 
would  not  be  benefited  by  a  wet  pack  if  his  struggles  continually  dis- 
arranged the  blankets,  so  as  to  allow  the  ingress  of  cold  air  to  his 
body;  neither  would  such  a  patient  be  aided  by  the  warm  full  bath  if 
his  full  strength  was  continually  being  exercised  to  escape  from  what 
might  be  to  him  a  horrifying  experience ;  but,  in  my  experience,  such 
cases  are  rare,  and  usually  can  receive  hydriatic  treatment  in  combina- 
tion with  the  administering  of  uyoscine  or  some  similar  drug. 

"  The  warm,  full  bath  has  been  used  comparatively  little  because  of 
the  lack  of  proper  facilities,  but  it  has  been  used  advantageously  in 
some  cases  of  infection,  motor  excitement,  and  restlessness  of  general 
paralytics  and  profound  neurasthenic  conditions,  characterized  by  in- 
somnia and  apprehensive  restlessness.  Almost  without  exception,  the 
result  has  been  a  rapid  cessation  of  the  active  motor  excitement,  fre- 
quently followed  by  sleep  while  in  the  bath  or  soon  after  removal. 
Patients  who  continued  struggling  against  the  immersion  have  been 
very  few.  The  technique  has  been  as  follows :  Cold  compress  to  head, 
frequently  cooled  and  replaced.  Body  immersed  in  tub  containing 
water  kept  between  a  temperature  of  90°  and  100°  F.  The  immersion 
has  varied  from  a  few  hours  to  ten  or  twelve,  and  has  been  followed 

*  Reprint  from  Proceedings  of  American  Medico-Psychological  Associa- 
tion, 1902. 


INSANITY.  491 

by  drying  body  and  placing  patient  in  bed  with  ample  covering,  and 
trying  to  promote  sleep.  Among  the  insane,  this  bath  requires  con- 
stant attendance  of  nurse. 

"  The  wet  pack  has  been  used  much  more  frequently  and  in  a  wider 
range  of  cases.  Roughly  speaking,  it  is  indicated  in  cases  of  motor 
activity,  feeble,  restless  delirium,  and  insomnia,  and  is  contraindicated 
only  in  the  small  percentage  of  cases  who  will  not  submit  to  the  pro- 
cedure after  repeated  and  careful  application.  The  technique  has  been 
that  given  in  Chap.  5,  Part  II.,  of  your  book. 

"  The  duration  has  varied  from  an  hour  or  two  to  the  entire  night 
in  many  instances  where  the  patient  has  slept  or  remained  quiet  and 
comfortable  during  the  longer  period.  The  average  duration  has  been 
three  hours.  The  procedure  has  been  followed  by  drying  of  body  and 
rest  in  bed,  provided  with  ample  covering.  Frequently,  sleep  follows 
soon  after  administration,  and  may  be  either  fitful  or  prolonged  through 
the  entire  night  without  removal  from  pack.  Usually,  the  patient 
tires  of  the  restraint  and  requests  removal  after  a  few  hours,  and  can 
reasonably  be  expected  to  have  continuation  of  sleep,  more  or  less  broken 
as  the  case  may  be,  during  the  remainder  of  the  night.  Rarely  have 
the  night  nurses  reported  "no"  sleep  during  the  night  following  wet 
packs.  I  could  cite  many  individual  cases  that  have  obtained  many 
more  hours  sleep  nightly  following  the  use  of  the  wet  pack  than  they  had 
enjoyed  prior  to  its  adoption,  and  the  result  could  not  be  attributed  to 
any  other  hypnotic  measure.  The  cases  are  largely  confined  to  the 
following  groups :  Manic  depressive  insanity  in  both  phases,  dementia 
prsecox,  the  best  results  being  obtained  in  the  katatonic  type,  senile 
delirium,  delirium  tremens,  and  neurasthenia.  I  am  convinced  that 
the  use  of  the  wet  pack  in  a  carefully  selected  series  of  cases  from 
these  groups  will  be  followed  by  an  increase  of  sleep  and  reduction  of 
motor  activity,  and  that  this  agent  has  none  of  the  objectionable  feat- 
ures of  the  chemical  hypnotics.  It  is  easily  applied  in  a  hospital  for 
the  insane,  and,  excepting  in  rare  cases,  does  not  require  a  special  at- 
tendant, which  is  a  marked  advantage  over  the  full  warm  bath.  Used 
in  routine  without  discrimination,  it  would  be  of  use  in  some  cases  and 
harmful  in  others,  whose  restlessness  prevented  proper  application, 
but  many  of  the  latter  will  yield  to  carefully  repeated  applications. 

"B.  As  a  Vasomotor  Tonic. — A  very  large  proportion  of  the  cases 
admitted  to  Danvers  show  a  disordered  nutrition  and  vasoniotor 
paresis,  more  or  less  profound,  and  characterized  by  enfeebled  cardiac 
action,  cold,  cyanotic  extremities  and  moist,  clammy  skin.  These 
cases  are  confined  to  no  groups  of  psychoses,  but  occur  alike  in  all. 
They  are  almost  without  exception  benefited  by  the  measures  employed 
in  the  douche  room,  and  these,  in  the  large  majority  of  cases,  are 
warmly  appreciated  by  the  patients.  The  applications  have  been  care- 
fully graded  to  the  patient's  individual  capacity  for  reaction.  The 
prescriptions  have  thus  varied  from  the  mildest  to  the  most  heroic 
measures.  Neurasthenic,  apprehensive  women  have  been  started  on  a 
course  by  drip  sheet  and  massage  in  the  wards,  the  temperature  being 
lowered  gradually  from  75°  to  60°  F. ,  and  this  followed  after  some  days' 


492        THE   PRINCIPLES   AND   PRACTICE   OP   HYDROTHERAPY. 

treatment  by  the  hot-air  bath  from  one  to  five  minutes,  supplemented 
by  the  fan  douche  ten  to  sixty  minutes'  duration,  temperature  from 
90°  to  70°  F.,  the  reaction  being  aided  by  subsequent  vigorous  friction, 
and  when  possible,  a  stroll  in  the  open  air.  Most  of  the  cases  can  be 
started  with  a  prescription  something  as  follows :  Hot-air  bath  to 
point  of  perspiration  (temperature  of  our  boxes  170°  to  180°  F.), 
circular  bath  or  rain  bath,  either  combined  or  separate,  temperature 
100°  to  90°  F.,  duration  thirty  to  sixty  minutes.  Fan  douche,  tem- 
perature 95°  to  85°  F.,  duration  thirty  to  sixty  minutes.  Spinal  jet 
douche,  temperature  80°  to  60°  F.,  duration  five  to  twenty  minutes. 
Pressure  fifteen  to  forty-five  pounds. 

"  Baths  given  twice  a  week  to  daily. 

"  Most  initial  prescriptions  vary  between  these  extremes  and  dura- 
tion, pressure  and  temperatures  are  changed  according  to  indications. 
The  treatment  usually  continues  over  a  period  of  months.  Easily  ob- 
served improvement  in  vasomotor  tone  and  general  nutrition  results 
from  this  treatment.  Bitter  tonics,  strychnine,  etc.,  are  sometimes 
given  in  connection  with  hydrotherapy.  Nearly  all  these  cases  show 
improvement  by  more  forcible  and  less  frequent  heart  action,  increased 
pulse  tension,  and  disappearance  of  cyanosis  and  stasis  of  peripheral 
circulation. 

"C.  As  an  Eliminative. — While  hydrotherapy  as  an  eliminative 
is  undoubtedly  of  benefit  in  cases  of  delirium  from  renal  lesions  and  in 
the  post-febrile  psychoses,  it  is  in  the  alcoholic  group  that  the  best  re- 
sults are  seen.  Most  of  these  patients  are  received  at  the  hospital 
suffering  from  acute  alcoholism  or  delirium  tremens,  and  their  natural 
suffering  has  been  frequently  increased  by  from  two  to  five  days'  in- 
carceration in  the  cells  of  a  police  station,  under  observation  and  await- 
ing the  usual  routine  of  commitment. 

"They  come  to  the  hospital  delirious  and  actively  hallucinated,  suf- 
fering from  malnutrition,  cardiac  weakness,  and  gastric  disturbance ; 
and,  while  nearly  all  can  be  expected  to  recover,  with  or  without  hy- 
driatic  measures,  I  am  confident  the  control  of  delirium  in  the  hallu- 
cinatory stage  is  sooner  obtained,  and  subsequent  convalescence  from 
the  results  of  a  toxic  state  hastened  by  the  measures  employed  here. 

"  During  the  past  four  years,  one  hundred  and  seventy-eight  men 
have  been  admitted  to  the  hospital,  suffering  from  the  varied  effects 
of  alcoholism.  About  seventy  per  cent  have  been  cases  of  delirium  tre- 
mens, and  among  the  latter  there  has  been  one  death.  The  patient 
in  question  was  very  ill  at  time  of  admission,  and  had  a  severe  bron- 
chitis. One  other  patient  was  admitted  who  had  a  history  of  excessive 
drinking,  and  was  suffering  from  lobar  pneumonia  at  the  time  of  com- 
mitment. His  death  followed,  but  while  here  he  showed  no  charac- 
teristic evidence  of  delirium  tremens. 

"  There  have  been  many  complications  among  the  cases,  principally 
of  pulmonary  and  renal  origin.  The  very  low  death  rate  is  an  argu<- 
ment  for  the  treatment  which  is  usually  much  as  follows :  The  first 
delirium  is  usually  controlled  by  giving  from  one  to  three  doses  of 
*D.  T.'  mixture,  containing  morphine,  potassium  bromide,  and  chloral 


INSANITY.  493 

•in  small  doses.  As  soon  as  the  patient's  condition  permits,  the  wet 
pack  is  employed  and,  under  the  combined  influence,  several  hours  of 
.quiet  sleep  are  obtained,  usually  within  forty-eight  hours  after  admis- 
sion. The  packs  are  continued  until  quiet,  natural  sleep  results,  which 
has  usually  followed  in  from  two  to  five  nights.  At  the  outset,  the 
bowels  are  opened  by  a  saline.  The  diet  at  first  is  liquid,  given  often 
and  in  large  quantities,  with  whiskey,  strychnine,  etc.,  given  only  in 
cases  needing  cardiac  stimulation.  Symptomatic  treatment  is  given 
as  indicated.  Usually,  before  the  end  of  first  week,  the  patient  is  ready 
for  douche-room  treatment,  which  is  given  upon  the  lines  before  men- 
tioned, with  the  addition  of  the  employment  of  hot  box  to  produce 
profuse  perspiration,  thus  endeavoring  to  obtain  the  full  elirninative 
effect  of  hydrotherapy  by  the  use  of  the  wet  pack  and  douche-room  pro- 
cedures, given  from  three  to  five  times  weekly. 

"  The  following  figures  concerning  the  last  twenty-five  alcoholics 
treated  in  the  douche-room  are  submitted.  Average  number  of  treat- 
ments per  case,  19.1.  Average  duration  of  treatment  per  case,  2.12 
months.  Average  gain  in  weight,  per  case,  14.2  pounds.  Coinci- 
dently  with  gain  in  weight  there  has  been  an  improvement  in  cardiac 
action,  digestion,  and  rapid  subsidence  of  mental  symptoms.  Patients 
suffering  from  drug  habits  have  received  practically  the  same  treatment, 
and  the  few  treated  here  in  recent  years  have  convalesced  rapidly. 

"  In  closing,  will  say  that  the  Scotch  douche  has  been  employed 
freely  in  cases  afflicted  with  vague  neuralgic  and  rheumatic  pains,  with 
apparent  relief  to  the  suffering,  real  or  fancied.  The  mental  status  of 
our  patients  nullifies  observations  of  this  character. 

"  The  distressing  vasomotor  symptoms  accompanying  the  meno- 
pause are  greatly  relieved  by  the  douche-room  treatment  extended  over 
a  long  period.  Frequency  and  severity  of  the  alternate  'hot  and  cold 
flushes  '  are  diminished  and  a  better  vasomotor  tone  results  from  the 
tonic  bath.  .  .  . 

"Thanking  you  for  the  kindness  and  courtesy  shown  me  while 
under  your  instruction,  I  am,  Very  truly  yours, 

"H.  W«  MITCHELL, 

"Assistant  Physician." 

In  a  paper  based  on  his  large  experience  in  the  Michigan  State 
Asylum  at  Kalamazoo  Dr.  A.  McGugan*  considers  the  problem  of 
treatment  of  the  acutely  insane  to  be  threefold :  1,  to  eliminate  waste 
products;  2,  to  limit  so  far  as  possible  the  output  of  energy;  and  3,  to 
feed  the  depleted  nerve  cells. 

Hydrotherapy  is  of  great  value.  Of  all  therapeutic  aids  in  the 
management  of  the  acutely  insane,  hydrotherapy  is  the  most  valuable 
and  most  generally  applicable.  Its  effects  can  be  classed  under  three 
headings:  1.  Sedative;  2.  Tonic;  3.  Eliminative.  For  sedative 
purposes  a  prolonged  tepid  bath  or  pack  is  used,  two  hours  or  even 

*  American  Medicine,  Feb.  22d,  1902. 


494       THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

longer.  Such  baths  are  indicated  by  insomnia  and  psychomotor  agita- 
tion, whether  exalted  or  depressed.  For  tonic  purposes  a  fifteen- 
minute  cold  pack  or  a  five-minute  cold  spray,  following  a  ten-minute 
warm  full  bath  or  hot  foot  bath,  is  used.  These  measures  are  indi- 
cated in  all  states  of  depression,  whether  from  pure  melancholia,  be- 
ginning dementia,  or  general  paresis.  For  elimination  the  warm  or 
tepid  pack  is  used,  followed  by  rubbing  with  alcohol.  "  Of  all  these 
procedures  the  most  useful  for  general  purposes  is  either  the  tepid  or 
the  warm  wet  sheet  or  blanket  pack,  followed  by  massage.  It  induced 
sleep  in  almost  any  kind  of  a  sleepless  case;  it  is  a  permissible  form 
of  restraint  in  cases  in  which  motor  restlessness  or  violence  is  a  symp- 
tom, and,  lastly,  it  is  one  of  the  most  effective  measures  for  increasing 
elimination  by  the  skin.  Its  immediate  effects  are  sedative,  its  ulti- 
mate effect  is  tonic.  It  is  indicated  in  states  of  elation  and  in  states 
of  depression.  In  careful  hands  it  is  contraindicated  in  scarcely  any 
case.  Its  application  is  easily  learned,  and  the  materials  required  are 
usually  obtainable  even  in  the  most  squalid  surroundings." 

In  the  annual  report  of  the  Eastern  Maine  Insane  Hospital  for 
1902,  Dr.  G.  W.  Foster,  the  superintendent,  writes :  "  It  is  perhaps  not 
stating  the  case  too  strongly  to  say  that  no  case  in  which  hydrotherapy 
has  been  employed  has  failed  to  show  nutritional  gain. 

"  Of  the  various  therapeutic  results  attained  by  its  aid  this  is  per- 
haps the  most  universal  and  far-reaching  in  its  effects  upon  the  vari- 
ous organs,  some  of  our  patients  showing  increase  in  weight  beyond 
what  they  have  ever  before  attained.  Upon  the  heart  and  blood- 
vessel walls  its  effects  are  particularly  perceptible  through  increased 
tone  and  flexibility,  thus  overcoming  in  a  degree  the  effects  of  vascular 
sclerotic  changes  and  apparently  causing  an  arrest  of  such  changes. 
The  latter  is  doubtless  a  difficult  matter  to  accurately  determine,  but 
it  is  an  impression  gained  by  nearly  ten  years'  extensive  use  of  this 
agent  in  a  variety  of  cases ;  and  the  attention  of  those  employing  it  is 
invited  to  this  point  for  confirmation  or  correction.  Upon  the  neurons 
in  all  their  parts  I  have  long  been  convinced  that  it  is  more  direct  and 
positive  in  its  action  than  any  other  therapeutic  agent  at  our  command. 
(See  report  of  the  Government  Hospital  for  the  Insane,  1897.) 

"  An  interesting  series  of  maniacal  cases  has  been  met  with  during 
the  year  in  which  acute  renal  complications  have  seemed  to  stand  in 
causal  relation  to  the  mental  symptoms,  as  well  as  to  other  symptoms 
of  grave  neuro-cerebral  type. 

"  I  have  before  me  clinical  histories  of  six  cases  bearing  a  resemblance 
in  symptoms,  and  manifesting  the  renal  complication.  There  are 
other  cases  more  or  less  typical  of  which  we  have  record,  but  these 
now  referred  to  all  occurred  among  those  discharged  during  the  year 
as  recovered. 


INSANITY.  495 

"The  symptoms  are  those  of  'acute  delirious  mania,'  having  the 
dry  brown  tongue,  rapid  pulse,  slight  to  moderate  elevation  of  tem- 
perature, motor  restlessness,  active  delirium  and  obstinate  insomnia, 
and,  in  some  cases,  a  degree  of  stupor.  Such  cases,  as  it  is  well 
known,  tend  to  rapid  exhaustion  and  death. 

"  The  renal  symptoms  have  consisted  in  marked  reduction  of  secre- 
tion, often  complete  retention,  requiring  catheterization ;  marked 
reduction  in  daily  excretion  of  urea  (to  one-quarter  normal  amount  or 
less),  notwithstanding  the  enormously  increased  metabolism ;  albumin, 
casts  or  blood  in  urine,  singly  or  in  combination. 

"  This  complexus  of  symptoms  presents  a  serious  problem  to  the 
medical  attendant.  The  clinical  history  of  the  cases  treated  here  in- 
dicates that  the  suppressed  renal  function  stands  in  the  relation  of  a 
cause  to  the  grave  cerebral  symptoms ;  for  the  latter  disappear  part 
passu  with  the  successful  local  treatment  of  the  former.  Therapy  by 
drugs  finds  but  a  slight  basis  in  either  theory  or  experience.  Diure- 
tics may  do  harm,  and  so  far  as  they  merely  increase  the  water  excreted 
can  do  no  material  good  if  the  organ  remains  engorged  and  its  excre- 
tory cells  paralyzed  in  their  function. 

"  A  safe  remedy  and  one  that  has  thus  far  proved  promptly  effectual 
in  all  cases  thus  complicated  occurring  at  the  hospital,  lies  in  the  use 
of  cold  wet  packs  applied  locally  over  loins  and  abdomen ;  in  general 
cold  packs,  and  cold  tub  baths — the  temperature  commonly  employed 
being  70°  F. 

"  The  local  packs  are  applied  continuously,  with  renewals  three  or 
four  times  daily,  until  the  urine  approaches  the  normal  amount  and 
quality.  Evidence  of  improvement  is  usually  perceived  within  twenty- 
four  hours,  or  at  most  forty-eight  hours ;  and  it  may  be  necessary  to 
continue  pack  from  two  to  five  or  six  days.  When  the  local  pack  is 
discontinued  a  general  cold  pack  (70°,  one  and  one-half  hours'  duration) 
is  given  daily  for  some  weeks. 

"  When  there  is  elevation  of  temperature  a  cold  tub  bath  is  given, 
as  may  be  indicated,  for  its  stimulating  and  temperature-reducing 
effects. 

"  I  confess  on  my  own  part  a  critical  turn  of  mind  toward  such 
published  accounts  as  the  foregoing  with  such  uniform  results  in  treat- 
ing a  grave  form  of  disease.  I  shall  not,  therefore,  take  it  as  cause 
for  surprise  if  some  should  fail  to  regard  it  seriously.  I  would  sug- 
gest, however,  that  the  test  is  readily  made,  and  the  means  are  always 
at  hand ;  there  is  no  other  reliable  means  of  relief,  and  the  prognosis 
of  the  condition,  untreated,  is  undeniably  grave. 

"  Eenal  engorgement  of  active  or  passive  type  does  not  contraindi- 
cate  the  use  of  tub  baths  at  70°  if  they  are  not  unduly  prolonged ;  but, 


496        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

on  the  contrary,  the  bath  is  salutary.  This  has  been  demonstrated  in 
the  nephritis  of  typhoid.  So  far,  however,  as  the  nephritis  alone  is 
concerned,  the  local  pack  should  have  the  preference  as  more  effectual 
and  convenient.  The  tub  bath  will  control  excitement  and  relieve  the 
nervous  symptoms,  if  the  bodily  temperature  is  above  normal,  and 
may  therefore  be  used  in  connection  with  the  packs.  I  would  here 
make  the  general  statement  that  no  diuretic,  within  the  limit  of  my 
experience,  is  at  once  so  effectual,  safe,  and  generally  applicable  as  the 
local  packs." 

The  chief  lesson  which  the  author  desires  to  impress  by  the  some- 
what extensive  quotations  from  the  reports  of  the  American  asylums, 
and  especially  by  the  reproduction  of  detailed  histories,  is  the  impor- 
tance of  an  exact  technique.  The  neglect  of  the  latter  has  brought 
this  remedial  agent  into  unmerited  desuetude.  Dr.  Foster's  remarks 
(page  494)  may  well  be  heeded  by  those  who  regard  water  as  so  sim- 
ple an  agent  that  neither  skill  nor  judgment  is  required  for  its  ad- 
ministration. 

The  following  extracts  from  foreign  authorities  may  also  serve  to 
emphasize  the  importance  of  definite  prescriptions  for  each  individual 
case.  In  the  text-book  on  "Clinical  Psychiatry,"  adapted  from  Krae- 
pelein's  "Lehrbuch  der  Psychiatric,"  by  Deffendorf,  hydrotherapy  ap- 
pears as  a  prominent  measure  in  the  management  of  nearly  all  tractable 
mental  diseases. 

"Exhaustion  Psychoses. — The  best  means  of  inducing  quiet  is  the 
prolonged  bath — 90°  to  100°,  fifteen  minutes'  duration,  and  even  to 
several  hours,  with  cold  cloths  to  the  head.  If  the  patient  exhibits 
fear  in  getting  into  the  bath  and  requires  holding,  the  bath  can  do  but 
little  good.  In  such  cases  hypodermics  of  hyoscine  hydrobrornate, 
gr.  ^.i_  to  gr.  -jl-jj-  or  fifteen  grains  of  sulphonal  may  be  given  in  com- 
bination with  the  bath.  Hypnotics  are  usually  contraindicated. 

"Acquired  Neurasthenia. — Next  to  isolation,  insomnia  must  be 
combated — but  before  resorting  to  medical  means,  hydriatics  should 
be  thoroughly  tried.  Of  these  the  most  serviceable  methods  are  the 
prolonged  warm  baths,  98°  to  100°  for  thirty  or  forty-five  minutes ; 
cold  ablutions ;  the  spray,  the  simple  douche,  and  the  dripping  sheet. 
In  the  last  method,  which  may  be  carried  out  at  home,  after  a  cold 
ablution  85°  to  75°,  the  patient  standing  in  warm  water  or  on  a  dry 
surface  with  a  cold  towel  about  the  head,  a  linen  sheet  dipped  into 
water  75°  to  55°  is  wound  dripping  about  the  patient ;  the  nurse  at  the 
same  time  applying  friction  until  reaction  takes  place.  The  douche, 
as  carried  out  at  a  bath  institution,  is  of  great  value. 

"Morphinism  (page  140). — The  greatest  restlessness  and  insomnia 
often  yield  to  ice  packs  to  the  head. 


INSANITY.  497 

"Dementia  Prcecox. — Insomnia  at  the  onset  may  be  controlled  by 
lukewarm  baths,  conditions  of  excitement  are  best  treated  by  pro- 
longed warm  baths,  the  extreme  excitement  sometimes  encountered, 
especially  in  the  katatonic  form,  may  not  yield  to  the  simple  warm 
bath,  in  which  event  one  may  successfully  employ  cold  packs,  at  first 
preceded  by  trional,  etc. 

"Melancholia. — Insomnia,  which  is  troublesome  and  often  difficult 
to  overcome,  is  best  relieved  by  warm  baths  98°  to  100°  which  may  be 
prolonged  for  an  hour ;  these  measures,  well  carried  out,  often  render 
hypnotics  unnecessary,  the  use  of  which  is  always  inadvisable  because 
of  the  prolonged  course  of  the  disease. 

"  Maniacal  Depressive  Insanity. — Unrestrained  activity  tends  to  in- 
crease the  excitement,  and  there  is  therefore  an  indication  to  limit  as 
much  as  possible  the  pressure  of  activity.  One  of  the  best  means  of 
accomplishing  this  is  confinement  to  bed,  especially  in  those  cases 
which  are  anaemic  and  debilitated.  In  severe  excitement,  prolonged 
warm  baths  give  excellent  results ;  it,  however,  may  be  necessary  in 
accustoming  the  patient  to  the  baths  to  temporarily  give  a  preliminary 
dose  of  sulphonal,  etc. ;  this  accomplished,  the  warm  bath,  properly 
applied,  will  often  relieve  the  greatest  excitement,  and  frequently  ren- 
der medicinal  treatment  unnecessary.  After  excitement  subsides,  the 
prolonged  bath,  combined  with  occasional  freedom  from  all  restraint, 
is  of  value." 

These  citations  from  a  recognized  high  authority  are  the  more  valu- 
able, in  the  author's  opinion,  because  the  description  of  the  technique 
of  some  of  the  procedures  by  Kraepelein  indicates  that  he  writes  from 
actual  practical  knowledge  and  not,  as  is  too  often  observed  with  regret 
in  some  of  our  literature  on  the  treatment  of  nervous  diseases,  from 
reading  and  imperfectly  grasping  the  rationale  of  the  procedures  rec- 
ommended. This  author's  frequent  recommendation  of  the  prolonged 
warm  bath,  the  temperature  of  which  he,  in  happy  contrast  to  many 
of  his  specialistic  colleagues,  never  fails  to  state,  would  justify  the 
reader's  attention  to  the  technique  of  this  procedure  as  described  on 
page  229.  One  point  should  never  be  neglected,  viz.,  to  maintain  the 
water  temperature  with  great  care,  and  by  watchful  nursing  and  before 
the  patient  is  returned  to  his  bed  to  have  the  latter  thoroughly  warmed 
and  the  patient  rubbed  dry  and  enveloped  in  a  hot  linen  sheet,  in 
order  that  the  cutaneous  hyperaemia  which  is  so  essential  in  the 
rationale  of  this  procedure  be  maintained.  When  the  patient  rises  out 
of  a  bath  of  100°  F.  into  an  aerial  temperature  of  70°,  the  cutaneous 
vessels  are  contracted,  unless  this  sudden  transition  is  counteracted  by 
the  hot  sheet  and  rapid  removal  to  the  warm  bed.  The  neglect  of  this 
obvious  oversight  is  the  frequent  cause  of  failure  of  this  simple  yet 


498         THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHEEAPY. 

effective  calmative  agent.  A  recent  review  of  Kraepelein's  hydriatrio 
methods  may  add  to  the  better  understanding  of  this  subject.  Keraval* 
writes :  "  Kraepelein,  of  Heidelberg,  allows  agitated  patients  to  lie  in  a 
bath  of  34°  C.  (93.2°  F.)  for  weeks  and  months.  Mania  and  the  deliri- 
ums of  paralytics  are  special  indications.  It  is  true  it  is  sometimes 
difficult  to  keep  these  patients  in  the  bath,  both  in  the  majority  of 
cases  who  may  succeed  by  patient  suasion,  sulfonal  and  hyoscine.  In 
catatonia  Kraepelein  prefers  the  wet  pack.  The  continuous  bath  oper- 
ates as  does  the  rest  in  bed,  only  it  acts  much  more  rapidly.  Still 
all  German  psychiatrists  are  not  convinced  by  Kraepelein ;  they  refer 
to  the  difficulty  of  executing  this  bath  and  its  great  expense,  also  to 
the  imperfection  of  isolation  involved,  as  objections.  Other  authors, 
however,  praise  these  baths,  and  laud  the  increase  of  tissue  change 
induced  by  them.  Taken  all  in  ally  these  continuous  baths,  when  adapted 
to  each  case,  represent  a  positive  enrichment  of  psychotherapy,  while  the 
cruel  douches  of  former  days  have  justly  been  discarded." 

Weygandtf  favors  continuous  baths.  "  Extraordinarily  valuable  are 
the  continuous  baths  in  conditions  of  great  excitement.  Sometimes 
it  requires  several  days  to  accustom  the  patients  to  it,  after  which 
they  feel  comfortable  in  the  water,  especially  the  maniacal,  kata- 
tonic,  paralytic,  and  delirious  patients.  The  bath  should  be  35°  C. 
(95°  F.)  of  ten  to  twelve  hours'  duration,  and  meals  may  be  given  in 
the  tub.  Feeble  patients  require  a  hammock  in  the  tub.  Menstrua- 
tion is  not  disturbed.  These  continuous  baths  are  specially  valuable 
in  bedsores,  which  heal  with  remarkable  promptness ;  also  for  injuries 
and  small  operations ;  antiseptics  should  not  be  added  lest  patients 
drink  of  the  water.  In  cachectic  patients  the  appetite  is  sometimes 
greatly  improved." 

W.  Alter  J  contributes,  in  an  article  on  hydrotherapy  in  the  psy- 
choses, a  clear  analysis  of  the  value  of  the  continuous  bath  of  one  to 
twelve  hours'  duration  and  wet  packs  of  one  to  twelve  hours'  duration. 
He  finds  warm  baths  of  one  to  six  hours'  duration  excellent  procedures 
for  sleeplessness  in  the  exacerbations  of  paranoiacs,  as  well  as  in  hebe- 
phrenic  katatonic  patients.  Prolonged  baths  (not  under  twelve  hours) 
proved  of  prime  service  in  hysterical  psychoses.  These  continuous 
baths  have  proven  an  absolutely  sovereign  agent  in  all  intense  states 
of  agitation.  Not  in  a  single  case  was  it  necessary  to  abandon  the 
bath  on  account  of  failure.  Seven  hundred  and  fifty-two  baths  were 
of  12  hours'  duration;  35  lasted  24  hours;  39  baths  36  hours;  6 baths 
for  2  days;  16  baths  3  days;  4  for  4  days;  5  for  5  days;  1  each  for 

*  Revue  de  Therapeutique,  No.  11,  1902. 

f  "Atlas  und  Grundrisse  der  Psychiatric,"  Miinchen,  J.  F.  Lehmann,  1902. 

j  Fortschritte  der  Medizin,  No.  36,  1903. 


INSANITY.  499 

6,  8,  14,  and  32  days.  The  largest  percentage  of  baths  was  admin- 
istered to  paretics  and  maniacal  cases  of  the  manic  depressive  group. 
The  continuous  bath  is  the  most  valuable  agent  in  neglected,  unclean 
cases,  proving  often  of  surprising  efficacy.  When  possible  Alter  con- 
fined himself  to  day  baths,  but  these  baths  usually  secured  good  nights 
in  most  instances.  Wet  packs  (88°  to  93°  ¥.)  up  to  twelve  hours' 
duration  acted  very  favorably  in  semi-quiet  but  sleepless  paretics. 
Many  preferred  packs  to  baths.  The  pack  is  indicated  in  severe  hal- 
lucinations and  agitated  melancholies.  The  greatest  precision  in  tech- 
nique and  selection  of  cases  is  necessary.  Alter  expresses  the  belief 
that  the  water  treatment  will  render  the  cell  treatment  quite  unnec- 
essary, superfluous,  and  diminish  the  resort  to  calmative  medication 
greatly.  "No  matter  how  expensive  it  may  be,  hydrotherapy  will 
always  prove  profitable." 

SUMMARY. — The  author  indulges  the  hope  that  the  above  clinical 
data  which  he  has  gathered  by  correspondence  and  careful  scrutiny 
of  publications  may  prove  an  incentive  to  alienists  to  study  more  thor- 
oughly the  principles  involved  in  the  application  of  water  in  health  and 
disease,  to  apply  it  with  precision,  and  to  incorporate  the  data  obtained 
from  observations  in  these  cases  in  the  histories  and  reports.  He  feels 
confident  that  by  this  course  many  valuable  developments  may  arise 
which  would  lighten  their  burdens  and  diminish  the  great  strain  of 
managing  these  unfortunates. 

Several  asylums  have  sent  their  physicians  and  nurses  to  this  city 
for  instruction  and  training,  the  results  of  which  may  be  discerned  in 
the  above  corrrespondence.  Dr.  Dent's  and  Dr.  Foster's  statements  on 
this  subject  may  well  be  heeded,  for  the  administration  of  water  has 
usually  been  regarded  as  not  requiring  skill,  judgment,  and  accuracy, 
an  error  which  the  large  experience  of  these  clinical  alienists  discov- 
ered, and  which  it  is  hoped  may  be  remedied  by  proper  instruction. 

LEGISLATIVE  ACTION   ON    THE   HYDROTHERAPY    OF  THE 

INSANE. 

The  enormous  importance  which  hydrotherapy  has  justly  attained 
in  the  management  of  the  insane  is  exemplified  by  the  result  of  the 
wise  and  humane  efforts  of  the  Illinois  Board  of  Charities  to  obtain  a 
large  appropriation  for  the  instalment  of  the  apparatus  required  for 
this  valuable  method  in  all  the  State  hospitals.  In  order  to  overcome 
the  opposition  rife  among  members  of  the  legislature  against  this  treat- 
ment, which  by  some  was  regarded  as  a  fad  and  still  in  the  experi- 
mental stage,  this  practical  board  obtained  the  views  of  eminent  alien- 
ists on  the  subject  and  convened  several  conferences  of  superintendents 
for  its  discussion. 


500        THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

The  author  is  indebted  to  the  able  secretary  of  the  Illinois  Board 
of  Charities,  Mr.  Graves,  for  advanced  sheets  of  its  report  to  the 
Governor  and  Legislature.  This  paper  is  so  full  of  important  infor- 
mation on  Hydrotherapy  and  of  vital  suggestions  to  asylum  superinten- 
dents that  the  author  feels  impelled  to  reproduce  it  in  abbreviated  form : 

Every  State  hospital  for  the  insane  in  Illinois  is  so  overcrowded 
that  within  six  months  it  will  be  necessary  to  return  patients  to  county 
almshouses.  Insanity  in  the  State  institutions  of  Illinois  is  increas- 
ing at  the  rate  of  three  hundred  and  seventeen  new  cases  each  year. 
Facing  this  problem,  and  informed  that  insanity  has  increased  to  an 
alarming  extent  during  the  last  fifty  years  and  that  it  is  becoming 
more  difficult  to  cure,  the  Board  of  Charities  has  developed  policies 
which,  if  carried  out,  promise  to  relieve  congestion  in  the  State  hos- 
pitals. 

1.  By  educating  physicians  at  hospital  clinics  to  detect  the  early  symptoms 
of  insanity  in  unstable  persons  and  by  early  treatment  prevent  their  commit- 
ment to  hospitals  for  the  insane. 

2.  By  treating  by  hydrotherapy  (water  treatment)  acute  cases   sent   to 
hospitals  early  in  the  illness  so  as  to  effect  as  many  cures  as  possible  and  relieve 
the  State  of  the  care  of  such  patients. 

3.  By  re-educating  chronic  insane  so  that  many  of  them  can  be  wholly 
or  partly  self-supporting  outside  of  hospitals. 

USE  OF  HYDROTHERAPY  ABROAD. 

Hydrotherapy  for  the  insane  is  used  with  marked  success  in  Europe, 
especially  in  Germany,  Holland,  France,  Belgium,  Italy,  Austria,  and 
Greece.  Cuba  and  Mexico  apply  it. 

USE  IN  THE  UNITED  STATES. 

The  following  is  a  list  of  public  and  private  hospitals  for  the  in- 
sane in  the  United  States  which  use  hydrotherapeutic  treatment  for 
patients : 

Here  follows  a  list  of  thirty-nine  institutions  in  New  York,  Con- 
necticut, Massachusetts,  Pennsylvania,  Michigan,  Ohio,  Wisconsin, 
Illinois,  California,  Maryland,  and  Rhode  Island. 

STATEMENTS  REGARDING  THE  VALUE  OF  WATER  TREATMENT 
FOR  INSANE. 

The  following  are  statements  from  men  of  experience  regarding 
the  value  of  hydrotherapy  in  the  treatment  of  the  insane : 

DR.  WILLIAM  A.  WHITE,  SUPERINTENDENT  GOVERNMENT  HOSPITAL  FOR  THE 
INSANE,  WASHINGTON,  D.  C. 

From  our  experience  here  I  am  inclined  to  the  belief  that  no  other  thera- 
peutic agent  is  so  valuable  as  hydrotherapy  in  such  an  institution.  .  .  . 
I  can  tell  you  in  a  few  words  that  the  results  of  our  experience  are:  In  the 
first  instance,  we  expect  by  the  aid  of  hydrotherapeutic  measures  to  prac- 
tically do  away  with  all  forms  of  restraint  whatever,  either  mechanical  or  chem- 
ical. The  most  recent  statistics  on  the  matter  of  restraint  in  our  hospital 
show  only  one  patient  in  nine  hundred  in  mechanical  restraint,  and  this  low 
proportion  is  especially  noteworthy  because  of  the  large  proportion  of 


INSANITY.  501 

criminals  of  a  dangerous  type  in  our  population,  and  it  is  due  in  the  main 
to  the  wide  use  of  hydrotherapeutic  measures.  In  addition  I  might  say 
that  in  a  great  many  of  our  cases  of  poor  nutrition  there  is  a  marked  im- 
provement in  the  condition  of  the  patients  under  treatment  notable  in  the 
main  by  their  gain  in  flesh. 

DR.  RICHARD  DEWEY,  PHYSICIAN  IN  CHARGE  OF  THE  MILWAUKEE  SANITA- 
RIUM, FORMERLY  SUPERINTENDENT  AT  KANKAKEE. 

I  consider  it  essential  in  accomplishing  curative  results.  There  is  nothing 
but  plain,  sober  fact  in  the  statement  that,  for  a  large  proportion  of  patients 
suffering  from  mental  trouble,  there  is  no  one  means  so  important. 

DR.  E.  C.  DENT,  LATE  SUPERINTENDENT  MANHATTAN  STATE  HOSPITAL  FOR 

THE  INSANE. 

In  using  hydrotherapy  we  dismiss  sedatives,  restraint,  seclusion,  and  many 
objectionable  features. 

The  superintendents  and  medical  directors  invariably  speak  highly  of 
hydrotherapy  and  its  various  forms  as  a  hypnotic  and  ehminative.  Where 
the  continuous  bath  is  used,  and  especially  in  the  German  clinics,  without 
exception,  they  place  the  procedure  in  the  foremost  rank  as  a  hypnotic. 
.  .  .  Prof.  Nissil,  the  Medical  Director  of  the  Clinic  for  Mental  Diseases, 
University  of  Heidelberg,  states  that  since  the  establishment  of  the  contin- 
uous bath  in  1903  he  has  abolished  sedatives  and  hypnotics  and  no  longer 
allows  seclusion.  In  this  clinic  patients  have  been  continuously  in  the  bath 
for  a  period  of  nine  months. 

FROM  MANHATTAN  HOSPITAL  SECTION    OF   NEW   YORK   COMMISSION   IN 
LUNACY,  SEVENTEENTH  ANNUAL  REPORT. 

The  two  continuous-bath  tubs  located  in  ward  23  have  been  in  almost 
constant  use  night  and  day  during  the  entire  year.  A  contract  has  been  let 
for  installing  eight  improved  continuous-bath  tubs  for  the  women's  division, 
and  four  for  the  men's  division.  We  expect  to  get  the  very  best  results 
obtainable  from  the  use  of  the  prolonged  warm  bath.  Patients  are  often 
continued  under  this  treatment  for  weeks,  remaining  in  the  tub  day  and 
night,  eating  and  sleeping  while  in  the  tub.  They  are  at  tunes,  however, 
taken  from  the  bath  for  the  purpose  of  anointing,  or  to  allow  a  change,  and 
are  then  placed  in  bed,  or,  if  their  condition  will  permit,  are  allowed  about 
the  ward  for  a  time. 

Very  few  remedies  of  a  sedative  class  are  now  given  in  this  hospital,  which  fact 
I  attribute  mainly  to  the  introduction  of  the  various  forms  of  treatment  by  hydro- 
therapy.  In  the  men's  division  hydrotherapy  has  been  put  into  practice 
with  the  most  gratifying  results. 

The  following  is  quoted  from  previous  notes  made  at  the  hospital: 

"In  acute  maniacal  conditions,  or  acute  delirium  states  characterized  by 
great  motor  activity,  the  prolonged  warm  bath  has  proven  very  efficacious. 
.  .  .  After  some  hours  in  the  bath  produces  sleep.  In  some  cases  of  in- 
somnia we  have  found  great  benefit  in  this  way  without  the  use  of  sedatives. 
In  acute  delirious  conditions  .  .  .  the  following  results  have  been  obtained: 
Restlessness  has  been  reduced,  sleep  promoted  and  temperature  reduced; 
we  have  also  noted  an  increase  of  appetite,  the  patient  taking  food  better, 
and  receiving  more  benefit  from  the  food.  ...  In  manic  depressive 
cases,  manic  form,  it  is  not  unusual  to  leave  the  patient  in  the  prolonged 
bath  four  or  five  days  or  even  weeks.  There  is  no  doubt  but  the  prolonged 
bath  is  a  great  benefit,  and  the  cases  from  a  mental  standpoint  are  much 
improved. 

DR.  CHARLES  W.  PAGE,  PHYSICIAN  TO  INSANE  HOSPITAL,  DANVERS,  MASS., 
FROM  TWENTIETH  ANNUAL  REPORT,  1898,  PAGE  22. 

In  our  experience  hydrotherapy  is  a  most  gratifying  substitute  for  hyp- 
notic and  sedative  drugs.  It  seldom  fails  to  relieve  insomnia,  and  several 


502        THE   PRINCIPLES  AND   PEACTICE   OF   HYDEOTHEEAPY. 

cases  that  could  not  be  controlled  by  drugs  readily  yielded.  It  calms  excite- 
ment, and  chronic  patients  subject  to  periodical  disturbances  have  had  their 
attacks  modified  and  cut  short  by  the  same  means.  Several  cases  of  pro- 
longed melancholia,  on  the  very  verge  of  dementia,  have  been  cured  while 
being  treated  simply  by  the  external  application  of  water. 

DR.    HENRY  C.   EYMAN,    SUPERINTENDENT  MASSILLON   STATE   HOSPITAL, 
MASSILLON,  OHIO. 

We  have  almost  superseded  drugs  with  hydrotherapy.  I  am  a  great  believer 
in  the  practicability  of  a  thorough  equipment;  in  fact  I  do  not  see  how  we 
could  run  an  institution  without  it. 

The  Government  Hospital  for  the  Insane  at  Washington,  D.  C.,  in  its  last 
report  to  the  Secretary  of  the  Interior,  states  the  following  as  to  the  efficiency  of 
the  hydrotherapeutic  equipment: 

"The  three  hydrotherapeutic  rooms  have  been  in  continuous  operation 
and  a  large  number  of  patients  have  been  treated  in  them.  This  method  of 
treatment  seems  to  be  highly  advantageous  and  is  especially  beneficial  in 
cases  of  the  noisy  and  the  disturbed  classes  of  patients,  wrho  are  often  ren- 
dered quiet  and  enabled  to  sleep  after  the  treatment.  The  success  of  this 
method  of  treatment  has  been  so  marked  that  it  is  hoped  during  the  coming 
year  to  extend  it  somewhat  by  the  introduction  of  the  continuous  bath." 
The  equipment  to  be  effective  should  consist  in  the  following  apparatus: 

1.  In  the  douche-room: 

a.  Controller-table  arranged  for  hot,  cold,  and  ice  water,  also  for  steam 
vapor.     It  should  control  the  shower,  perineal  douche,  sitz-bath  and  full- 
bath.     It  should  have  the  necessary  regulating  and  mixing  valves,  the, 
non-scalding  valve,  thermometers,  pressure-gauge,  and  clock. 

b.  Shower  and  needle-spray,  well  built  and  supported  in  the  floor.     It 
is  to  provide  side  sprays  and  overhead  douche,  and  is  to  be  fed  from  the 
controller-table  with  water  of  any  desired  temperature  and  pressure. 

c.  The  sitz-bath,  also  controlled  from  the  table. 

d.  Full-bath  with  same  control. 

e.  Massage-table,  preferably  of  marble. 

2.  The  continuous  bath. 

3.  The  electric-light  and  hot-air  cabinets. 

4.  The  necessary  rooms  for  dressing  and  resting. 

Every  institution  for  the  insane  which  takes  care  of  excitable  patients  needs 
the  special  continuous  baths,  the  number  and  distribution  of  which  depend 
entirely  upon  local  conditions  and  class  of  patients  received. 

Whenever  possible,  a  special  small  hospital  ward  should  be  established  for  the 
care  of  acute  excited  patients,  and  such  ward  should  have  at  least  one  such  bath 
for  every  four  or  five  patients,  so  that  during  the  most  acute  stage  a  patient 
may  be  left  in  the  bath  for  a  prolonged  period. 

It  is  much  preferred,  however,  to  have  a  special  building  built  for  the  purpose 
of  housing  and  treatment  of  this  class  of  patients,  as  an  ordinary  ward  never  fully 
answers  the  purpose. 

The  cost  of  an  equipment  would  be  about  as  follows: 

1.  A  controller-table  with  douche  and  spray,  sitz-bath,  perineal   bath, 
and  massage-table,  from  $800.00  to  $900.00. 

2.  A  hot-air  or  electric-light  cabinet,  each  $200.00. 

3.  Each  continuous  bath  with  mixing  chamber,  non-scalding  valve,  large 
outlet,  etc.,  $95.00. 

4.  Necessary  plumbing,  according  to  location,  from  $300.00  to  $500.00. 

5.  Cement  or  terrazo  floor,  marble,  furniture,  etc.,  from  $500.00  to  $1.000. 
Taking  for  a  basis  the  requirements  of  a  hospital  of  about  fifteen  hundred 

patients  of  mixed  type  and  figurine  upon  about  forty  excited  patients  needing 
special  attention,  the  total  cost  should  not  exceed  $3,000.00,  should  the  apparatus 
be  installed  in  wards  already  existing. 

If  a  new  building  is  to  be  provided  with  a  capacity  for  forty  patients,  its  cost. 


INSANITY.  503 

including  all  the  apparatus  mentioned,  the  building  of  fireproof  construction 
with  a  system  of  forced  ventilation  and  heating  and  with  special  safeguards  pro- 
vided for  the  supervision  of  patients,  should  not  exceed  $36,000.00  or  $40,000.00. 
The  committee  recommends  on  the  basis  of  foregoing: 

1.  That  each  hospital  for  the  insane  be  provided  with  a  modern  hydro- 
therapeutic  equipment  at  the  earliest  possible  time. 

2.  That  each  hospital  make  a  provision  to  teach  hydrotherapy  to  its 
nurses,  preferably  through  a  regular  training-school  course. 

3.  That  so  far  as  the  resources  of  the  State  permit  each  institution  be 
provided  with  a  special  building  for  the  hydrotherapeutic  treatment  of  acute 
excited  patients. 

4.  That  where  such  an  appropriation  cannot  be  secured,  at  least  sufficient 
equipment  be  provided  and  installed  in  wards  now  existing  to  permit  cf 
effective  hydrotherapeutic  treatment  of  acute  cases. 

5.  That  the  proportion  of  acute  excited  cases  received  determine  the 
location  of  the  most  extensive  hydrotherapeutic  institute. 

D.  C.  MEAD,  M.D.,  SUPERINTENDENT  SOUTH  DAKOTA  STATE  HOSPITAL. 

Personally  I  regard  hydrotherapy  as  the  most  important  single  therapeitic 
agency  at  present  known  in  the  treatment  cf  conditions  met  with  in  institu- 
tions of  this  character. 

TEXT  OF  SPECIAL  COMMITTEE  REPORT. 

The  following  is  the  report  of  the  special  committee  on  Hydro- 
therapy  and  Industrial  Re-education  and  Recreation : 

CHICAGO,  Dec.  14,  1906. 
To  the  Honorable  the  Board  0}  State  Commissioners  of  Public  Charities: 

Your  Committee  on  Hydrotherapy  and  Industrial  Re-education  and  Recrea- 
ticn  has  investigated  and  jointly  discussed  the  several  problems  referred  to  it, 
and  wishes  to  report  the  following  as  its  joint  conclusions  and  recommendations: 

HYDROTHERAPY. 

The  eTectiveness  of  water  treatment  is  through  its  mechanical,  thermal,  and 
chemical  properties,  which  can  be  made  of  soothing,  stimulating,  or  irritating 
nature  as  desired.  Through  these  properties  it  is  capable  of  producing  the  follow- 
ing general  results: 

1.  To  very  effectively  change  the  distribution  of  blood  in  the  various 
parts  of  the  human  body,  that  is: 

a.  Reduce  local  congestion. 

b.  Relieve  local  anaemia. 

c.  Increase  or  decrease  velocity  and  tension  of  blood  current. 

2.  To  decidedly  affect  respiration: 

a.  By  increasing  it. 

b.  By  decreasing  it  both  in  volume  and  frequency. 

3.  To  very  promptly  affect  muscular  tone  and  energy: 

a.  Increase  muscular  tone. 

b.  Reduce  muscular  tension. 

4.  To  radically  affect  bodily  temperature: 

a.  Increase  body  temperature. 

b.  Reduce  body  temperature. 

5.  To  affect  the  peripheral  and  central  nervous  system  by: 

a.  Decreasing  its  irritability.  f 

b.  Increasing  its  sensitiveness  and  irritability. 

6.  To  affect  tissue  changes,  including  secretion,  excretion  and  absorption, 
therefore  general  nutrition,  chiefly  by  its  action  upon  circulation. 

7.  To  either  decrease  or  increase  elimination  of  waste  products  not  cn.'y 
through  the  skin,  but  through  other  organs  of  elimination. 


504        THE  PRINCIPLES  AND  PRACTICE  OF  HYDROTHERAPY. 

These  results  may  be  obtained  in  the  hands  of  a  skilled  operator  with  no  detri- 
mental secondary  effects,  and  in  that  respect  hydrotherapy  is  to  be  preferred 
to  any  other  remedy. 

Hydrotherapy  is  of  genuine  value  in  every  variety  of  insanity.  In  the  most 
trying  forms,  maniacal  and  delirious,  it  is  of  greater  value  than  any  other  treat- 
ment known. 

Hydrotherapy  has  passed  the  experimental  stage.  Its  results  are  not  theo- 
retical but  positively  proven.  In  various  hospitals,  particularly  in  Europe,  hydro- 
therapy  has  been  used  extensively  in  the  treatment  of  insanity  for  many  years. 
Professor  Kraepelin,  as  an  instance,  has  used  it  in  his  clinic  for  about  sixteen 
years  and  is  enthusiastic  about  its  efficiency. 

The  result  of  the  report  which  incorporated  the  above  opinions 
and  deductions  was  brilliant.  The  Governor  devoted  a  considera- 
ble part  of  his  message  to  an  intelligent  and  practical  statement  of 
the  immense  value  of  hydrotherapy  in  cases  of  insanity  and  "  heart- 
ily favored  the  extension  of  this  system  of  treatment  to  all  the  State 
hospitals  receiving  acute  cases."  This  action  was  so  remarkable  and 
unprecedented  that  The  Medical  Record  devoted  an  editorial  to  it  with 
the  caption  "  Therapeutics  in  a  Governor's  Message."  The  Legisla- 
ture appropriated  the  sum  asked  for.  The  wisdom  of  this  board  is 
illustrated  by  the  subjoined  letter,  and  it  is  cited  as  an  example  worthy 
of  emulation : 

"STATE  OP  ILLINOIS, 
THE  BOARD  OP  STATE  COMMISSIONERS  OP  PUBLIC  CHARITIES. 

SPRINGFIELD,  June  8th,  1907. 

"DEAR  DR.  BARUCH: — As  the  General  Assembly  has  provided 
money  for  installing  hydrotherapeutic  equipment  in  each  of  the  Illinois 
State  hospitals  for  the  insane,  the  superintendents  are  anxious  to  avoid 
making  any  serious  errors  in  selecting,  installing,  and  operating  the 
apparatus.  May  I  ask  you  to  write  me,  so  that  our  superintendents 
may  have  the  benefit  of  your  experience,  a  statement  of  what  several 
devices,  with  names  and  addresses  of  makers,  you  would  recommend 
for  use  in  hospitals  receiving  all  kinds  of  insane  cases,  pointing  out 
possible  errors  in  selection  and  installation?  How  would  you  go  about 
to  secure  a  suitable  instructor  in  the  use  of  hydrotherapeutic  apparatus, 
and  how  long,  in  your  judgment,  would  it  take  to  properly  train 
enough  attendants  to  skilfully  handle  apparatus  for  hospitals  of  1,200 
patients  and  of  from  2,000  to  2,500  patients?  About  what  would  it 
cost  a  month  for  a  suitable  instructor? 

"As  the  money  for  the  water  outfits  will  be  available,  it  is  ex- 
pected, within  a  few  weeks,  I  earnestly  solicit  an  early  reply  to  this 
letter. 

"Thanking  you  in  advance  for  such  assistance  as  you  can  see  your 
way  to  give,  I  am 

"Very  truly  yours, 

"  WILLIAM  C.  GRAVES,  Secretary, 

"M." 


CHAPTER  XXIX. 
THE  HYDRIATRIC  PRESCRIPTION. 

THE  reader  who  has  carefully  followed  the  description  of  hydriatric 
procedures  and  their  rationale  detailed  in  the  foregoing  pages  may  now 
appreciate  the  necessity  for  precision  in  the  prescription  of  these  pro- 
cedures by  the  physician,  and  for  exactness  in  their  execution  by  the 
attendant.  There  are  many  conditions  which  are  essential  to  the  suc- 
cess of  hydriatic  treatment,  and  in  which  the  well-informed  physician 
need  not  be  instructed  if  he  has  fully  mastered  the  rationale  of  the 
procedure  he  desires  to  apply  and  the  "  hydrotherapeutic  law  "  govern- 
ing its  application  to  the  concrete  case.  There  are  some  general  rules, 
however,  which  need  to  be  regarded  with  special  care.  Many,  indeed 
most,  procedures  may  be  readily  executed  at  the  patient's  home.  Es- 
pecially is  this  the  case  in  acute  disease  in  which  ablutions,  half  and 
full  baths,  wet  packs,  or  affusions  are  indicated.  The  fact  should 
be  ever  present  in  the  physician's  mind  that  a  reaction  sufficient  to 
fulfil  the  therapeutic  indications,  i.e.,  adapted  skilfully  to  the  condi- 
tion of  the  patient  and  his  malady,  should  be  produced.  In  chronic 
cases  even  greater  care  is  necessary,  and  for  this  reason  many  cases  do 
much  better  in  hydriatric  institutions,  where  experienced  physicians 
and  attendants  are  accessible.  The  constitutional  peculiarities — the 
age,  sex,  condition  of  blood-vessels,  and  nervous  irritability — should 
be  carefully  ascertained.  For  instance,  patients  advanced  in  years, 
in  whose  vessels  atheromatous  changes  have  taken  place,  should  not 
be  subjected  to  prolonged  procedures,  which  would  throw  too  great  a 
strain  upon  the  inelastic  and  feeble  vascular  coats;  patients  who  are 
anaemic  or  suffer  from  defective  nutrition  should  not  be  subjected  to 
procedures  which  abstract  much  heat.  At  the  same  time  it  should  be 
borne  in  mind  that  brief  applications  of  cold  water,  delivered  under 
high  pressure  or  accompanied  by  good  mechanical  irritation,  are  use- 
ful for  anaemic  cases,  because  they  do  not  abstract  heat  and  aim  by 
their  evanescent  action  to  call  forth  a  reaction  which  fills  the  cutane- 
ous vessels  and  counteracts  the  anaemic  condition. 

Some  patients  present  idiosyncrasies  which  are  as  striking  in  hydro- 
therapy  as  they  are  in  medicinal  therapy.  Contrary  to  the  old  hydro- 
pathic practice  which  is  to-day  not  sufficiently  disregarded,  the  author 
deems  it  wise  in  all  cases  to  begin  with  the  mildest  procedures,  and  in- 
crease the  duration  and  pressure,  and  diminish  the  temperature  cau- 


506        THE   PRINCIPLES   AXD   PRACTICE   OP   HYDRO-THERAPY. 

tiously,  until  the  patient's  reactive  capacity  has  been  ascertained.  A 
somewhat  extensive  experience  has  convinced  him  that,  although  water 
is  a  simple  remedy  and  so  easily  applied  that  any  one  seems  justified  in 
using  it,  he  must  insist,  with  full  consciousness  of  the  import  of  his 
words,  that  no  remedy  in  the  entire  materia  medica  demands  as  clear 
judgment  and  as  much  knowledge  of  the  patient's  condition  as  does  the 
application  of  water. 

The  complicated  nature  of  hydrotherapy  becomes  evident  when  we 
regard  the  fact  that,  unlike  other  remedial  agents,  there  are  several 
distinct  elements  involved  in  its  "  dosage. "  Water  is  for  this  reason 
capable  of  more  varied  and  changeable  dosage  than  any  other  remedial 
agent :  its  capacity  for  being  applied  in  the  solid,  fluid,  or  vaporized 
(steam)  state ;  the  various  methods  of  technique  to  which  it  may  be 
subjected  facilitate  its  adaptation  to  the  most  varied  conditions  of 
disease. 

Since  the  chief  therapeutic  effect  of  water  is  derived,  as  we  have 
seen,  from  its  thermic  and  mechanical  action  upon  the  cutaneous  sur- 
face, wo  find  three  methods  of  "  dosing"  it — by  changing  the  tempera- 
ture, mechanical  impact,  and  duration  of  the  application. 

1.  Temperature. — That  the  effect  of  any  water  application  at  40° 
F.  differs  from  that  of  water  applications  at  110°   (both  being  within 
safe  limits)  is  well  understood;  but  the  fact  is  rarely  grasped  that 
this  represents  an  enormous  latitude  for  grading  its  effect  upon  the 
human  organism. 

2.  Mechanical  Impact  (Pressure). — The  difference  in  effect  due  to 
the  method  by  which  water  is  applied  to  the  skin  is  not  sufficiently 
recognized,  and  yet  I  need  only  refer  to  the  fact  that  water  applied  by 
squeezing  from   a  sponge  or  by  submerging  the  patient  in  a  tub  of 
water   (without  any  friction)  produces  quite  a  different  effect,  sub- 
jectively and  objectively,  from  that  produced  by  water  applied  with 
active  friction,  as  in  the  Brand  bath  or  delivered  upon  the  body  with 
thirty  or  forty  pounds'  pressure  as  in  the  douche. 

In  a  lecture*  which  the  author  had  the  honor  to  deliver  by  invita- 
tion of  several  medical  teachers,  in  the  German  Hospital  of  Philadel- 
phia, the  effect  of  pressure  was  demonstrated  as  follows : 

A  patient  whom  the  house  physician  Dr.  Frese  represented  as  being 
in  an  ordinary  condition  of  health,  except  that  he  was  syphilitic,  was 
selected.  A  jet  douche  upon  the  back  at  a  temperature  of  80°  F.  for 
two  minutes,  under  a  pressure  of  thirty  pounds  to  the  square  inch,  was 
applied.  Wherever  the  stream  impinged  upon  the  skin  the  latter 
assumed  a  bright  red  hue;  the  cutaneous  arterioles  were  dilated.  He 
did  not  complain  much  of  cold,  although,  being  unaccustomed  to  such 
treatment,  he  did  not  find  it  very  agreeable. 

*  International  Clinics,  vol.  ii.,  seventh  series,  1897. 


THE   HYDRIATIC   PRESCRIPTION.  507 

When  the  pressure  of  the  stream  was  reduced  to  ten  pounds,  as 
indicated  by  the  gauge,  the  skin  was  scarcely  reddened,  while  an 
increase  of  pressure  to  thirty  pounds  brought  out  a  red  line,  marking 
distinctly  its  course  of  impact.  This  experiment  explained  that  we  have 
a  latitude  of  twenty-five  pounds  in  this  hospital  apparatus  (others  fur- 
nish more  or  less),  by  which  we  may  grade  the  force,  and  consequently 
the  stimulating  effect  of  the  stream  upon  the  sensory  cutaneous  nerve 
endings  and  the  cutaneous  vessels. 

When  the  same  stream  of  water,  which  was  applied  to  the  fairly 
robust  syphilitic,  was  directed  upon  an  emaciated,  phthisical  patient, 
whom  Dr.  Frese  had  also  placed  at  our  disposal,  and  who  had  just 
emerged  from  a  hot-air  bath,  which  facilitates  reaction,  very  little 
redness  was  evoked,  because  the  circulation  of  the  patient  was  feeble. 

This  illustrates  that  water  applications  may  be  graded  also  accord- 
ing to  the  condition  of  the  individual. 

3.  Duration. — Another  important  mode  of  grading  or  dosing  water 
applications  is  by  the  duration  of  the  procedure.     If  we  dip  one  hand 
into  a  bucket  of  water  at  40°  F.  for  one  second,  remove  it,  and  dry  it, 
the  skin  will  assume  a  ruddy  hue,  grow  warm,  and  feel  comfortable.    If 
we  dip  the  other  hand  into  the  same  water  for  five  minutes,  considerable 
pain  will  be  produced ;  the  skin  will  become  mottled,  cyanotic,  and,  after 
it  is  dried,  a  considerable  time  will  elapse  ere  warmth  and  comfort  are 
restored.     The  effect  of  duration  when  the  temperature  and  the  sub- 
ject are  the  same  is  made  evident  by  this  simple  experiment.     The 
duration  of  a. water  application  offers, •  therefore,  by  judicious  gradua- 
tion, an  excellent  mode  of  "  dosing"  the  remedial  action  of  water. 

4.  Technique. — The  various  modes  of  applying  water  afford  another 
method  of  dosing  it,  viz.,  making  the  effect  feeble  or  intense.     An 
ablution,  for  instance,  at  60°,  is  a  mild  application,  because  it  attacks 
only  portions  of  the  body  successively,  while  a  full  bath  at  the  same 
temperature  would  be  obviously  so  intense  that  it  must  be  used  with 
great  caution ;  a  half-bath  of  the  same  temperature  and  duration  would 
be  less  intense,  etc. 

A  familiar  example  of  the  influence  of  varying  procedures  upon  the 
therapeutic  effect  is  offered  in  the  application  of  cold  water  in  the 
resuscitation  of  the  still-born  infant.  Sprinkling  the  face  and  chest 
with  ice  water  suffices  in  mild  cases.  If  response  cannot  be  thus  ob- 
tained, slapping  with  a  wet  towel — adding  the  mechanical  effect — is 
resorted  to;  this  failing,  dipping  into  cold  water  sometimes  succeeds, 
and  in  extreme  cases  alternate  dipping  into  hot  and  cold  water  offers  a 
more  intense  stimulation  of  the  sensory  terminals,  which  convey  the 
excitation  to  the  central  nervous  system  and  arouse  the  reflex  inspira- 
tory  effort  which  sets  the  wheels  of  life  into  motion. 


508       THE   PRINCIPLES  AND   PRACTICE  OF  HYDROTHERAPY. 

That  regard  to  the  individual  case  is  also  demanded  in  the  adapta- 
tion of  hydriatric  technique  is  made  plain  by  the  fact  which  the  veri- 
est tyro  in  medicine  must  appreciate,  that  the  procedures  adapted  to 
the  still-born  child  would  be  absurdly  ineffective  in  a  typhoid  case, 
and  on  the  contrary  the  friction  bath  which  refreshes  the  latter  would 
be  fatal  to  the  former.  These  self-evident  propositions  are  mentioned 
only  to  emphasize  that  failure  to  obtain  good  results  is  frequently  due 
to  faulty  technique,  and  that  precision  must  be  observed  in  prescribing 
it  and  in  executing  the  prescription. 

Errors  Commonly  Committed. — In  order  more  earnestly  to  impress 
this  necessity  of  correct  technique,  some  of  the  errors  often  committed 
by  otherwise  well-informed  men  will  be  pointed  out,  and  thus  some 
useful,  practical  lessons  for  the  guidance  of  the  reader  may  be  incul- 
cated by  example. 

The  history  of  the  remedial  use  of  water  demonstrates  that  no  other 
remedy  in  our  entire  therapeutic  armamentarium  has  experienced  so 
many  changes  in  the  estimation  of  physicians.  At  one  time  lauded  to 
the  skies,  it  appears  at  another  period  entirely  neglected;  so  that, 
despite  its  antiquity,  water  has  not  obtained  a  firm  footing  in  therapeu- 
tics; despite  its  marked  clinical  results,  it  still  requires  to  be  brought 
to  the  attention  of  practitioners;  despite  its  espousal  by  the  best 
authorities  in  ancient  and  modern  practice  and  literature,  the  average 
medical  man  is  not  familiar  with  its  history,  action,  and  merits. 

Indifference  to  a  definite  technique  in  the  application  of  water  has 
been  the  chief  obstacle  to  the  recognition  of  its  value,  and  has  ren- 
dered its  application  in  the  hands  of  many  unsuccessful  and 
discouraging. 

Failure  is  the  sure  result  of  inattention  to  details.  As  a  physician 
must  judge  the  value  of  a  remedy  by  his  experience,  it  follows  that 
failures  to  achieve  the  results  which  the  experience  of  others  had  led 
him  to  expect  has  brought  this  remedy  into  disrepute,  the  fact  unhap- 
pily remaining  unrecognized  that  not  the  remedy  but  its  application  was 
at  fault. 

Our  medical  schools  with  very  rare  exceptions  do  not  include  hydro- 
therapy  in  their  curriculum,  the  therapeutic  use  of  water  being  curso- 
rily mentioned  in  the  lectures  on  materia  medica.*  Some  text-books  on 
the  latter  teach  it  in  a  faulty  manner.  Witness  the  following  quota- 
tion from  the  thirteenth  edition  of  a  justly  popular  text-book  (page 
39) :  "  The  object  of  the  bath  is  a  reduction  of  temperature,  and  unless 
this  is  effected  there  are  no  good  results." 

*  Since  the  above  was  written  a  Chair  of  Hydrotherapy  has  been  established 
in  Columbia  University,  with  a  tri-weekly  clinic,  and  medical  instruction  is 
given  in  a  few  other  schools. 


THE   HYDRIATRIC   PRESCRIPTION.  509 

Thus  has  it  come  about  that  not  only  is  the  average  medical 
man  poorly  informed  upon  this  subject,  but  even  among  eminent 
men  in  our  profession  a  deplorable  indefiuiteness  exists  upon  the  prin- 
ciples and  practice  of  hydrotherapy,  which  is  manifest  in  society  dis- 
cussions and  in  the  lectures  from  which  our  young  men  expect  to  derive 
instruction.  A  few  examples  to  illustrate  the  correctness  of  this  state- 
ment may  interest  the  reader  and  prove  instructive  by  pointing  out  the 
faults  most  commonly  committed. 

In  a  discussion  on  "  The  Treatment  of  Pneumonia  of  Infancy  and 
Childhood,"*  the  following  reference  is  made  to  hydrotherapy  by 
a  justly  eminent  teacher :  "  The  best  antipyretic  is  cold.  Cold  bathing 
was  once  eulogized  immensely,  and  again  abhorred  and  warm  bathing 
placed  in  its  stead.  The  rationale  of  cold  bathing  is  the  cooling  of  the 
surface  (that  is,  of  fourteen  feet  in  the  adult,  proportionately  in  the 
young),  with  its  immense  surface  circulation.  As  long  as  this  contin- 
ues active,  new  blood  will  come  to  the  surface  every  moment  and  the 
whole  body  is  thereby  cooled.  When  it  is  no  longer  active,  the  heart 
is  weak,  the  extremities  are  cold,  cold  bathing  is  dangerous.  The  rule  I 
have  prescribed  many  years  ago  was  this :  No  cold  bath  when  once 
after  it  the  extremities  remain  cold  or  cool." 

This  lecturer  refers  to  the  fact  that  he  had  "  preached  and  practised 
this  theory  almost  a  score  of  years  previously,"  and  had  at  that  time 
said:f  "If  there  be  anything  I  should  rely  upon  in  pneumonia,  espe- 
cially lobar  pneumonia,  when  the  fever  is  very  high,  it  is  cold-water 
treatment."  He  also  refers  in  this  article  to  the  prejudice  existing 
against  cold  water,  a  prejudice  to  which  he  attributes  his  expulsion 
from  the  staff  of  a  hospital  at  that  time.  He  prophesied  at  that  time 
that  "  this  prejudice  would  disappear,  just  as  the  prejudice  against  pure 
air  has  disappeared." 

That  this  prophecy,  made  ten  years  previously,  has  not  been  fulfilled 
is  evident  from  the  following  extract  from  Hare's  "  American  System  of 
Therapeutics,"  page  605,  vol.  i.,  1891:  "It  seems  strange  that  Ameri- 
can physicians  who  are  usually  so  prompt  in  giving  all  therapeutic 
measures  a  thorough  and  complete  trial,  should  have  so  largely  neglected 
and  even  condemned  without  adequate  experience  these  measures." 

Why  has  the  enthusiastic  advocacy  of  an  able  teacher,  who  has 
deservedly  been  followed  by  the  profession  in  other  respects,  fallen 
barren,  so  that  to-day  the  prejudice  against  the  water  treatment  is 
almost  as  great,  especially  in  America,  as  ever  it  was? 

The  reason  is  not  far  to  seek.  Had  this  author  given  more  definite 
directions  how  cold  the  water  should  be,  the  duration  of  his  bath  or 
pack,  the  frequency  of  bathing  or  packing,  his  teachings  would,  I 

*  Archives  of  Pediatrics,  April,  1893.  f  Medical  Record,  p.  289,  1870. 


510        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

opine,  have  taken  root,  and  would  to-day  have  borne  golden  fruit  in 
the  hands  of  others,  as  the  practice  has  done  in  his  own  hands.  The 
author  was  careful  enough  to  give  in  the  same  essay  minute  directions 
as  to  what  he  means  by  large  doses  of  digitalis,  and  how  these  and 
other  medicinal  agents  are  to  be  given.  But  in  his  references  to  bath- 
ing he  is,  like  too  many  other  able  writers  and  teachers,  content  to  leave 
the  important  minutiae  to  his  reader's  judgment.  Many  of  the  latter 
would  properly  regard  "  cold  water"  as  water  to  which  nothing  is  added, 
or  just  as  it  is  obtained  from  the  source  of  supply.  The  danger  of  such 
indefmiteness  is  made  evident  by  the  fact  that  in  New  York  City  the 
temperature  of  the  Croton  water  varies  from  45°  in  December  to  75° 
in  August.  It  will  be  readily  seen  that  to  the  sensitive  organism  of  a 
child  it  cannot  be  a  matter  of  indifference  whether  water  at  45°  or  at  75° 
is  applied.  Indeed,  to  a  child,  a  "  bath"  at  75°,  and  even  "  packs" 
in  sheets  wrung  out  of  water  below  60°,  would  be  dangerous.  The 
lesson  is  evident  that,  in  prescribing  "cold-water  treatment,"  or,  more 
correctly,  "water  treatment,"  physicians,  especially  teachers,  should  be 
careful  in  giving  as  minute  directions  with  regard  to  temperature,  dura- 
tion, and  method  as  they  are  in  the  habit  of  doing  when  referring  to  medi- 
cinal agents.  The  terms  cold  water,  warm  water,  lukewarm  water, 
hot  water,  indicate  approximate  temperatures  upon  which  there  is  no 
consensus  of  opinion.  Hence,  it  is  far  more  scientific  to  abandon  these 
terms,  and  always  refer  to  water  at  definite  degrees  of  temperature,  at 
defined  pressure,  giving  clearly  defined  methods,  duration,  and  fre- 
quency of  repetition.  This  has  been  my  unvarying  practice  for  many 
years.  I  have  reiterated  it  upon  every  occasion,  because,  as  I  have 
shown,  the  value  of  these  therapeutic  procedures  depends  upon  such 
precision,  and  their  universal  adoption  can  be  expected  only  when  their 
value  can  be  demonstrated  by  comparing  results  of  many  observations 
made  under  similar  conditions. 

In  contrast  to  the  above  faulty  teaching  may  be  cited  that  of  A. 
Baginsky,*  who  reports  on  thirty  cases  of  croupous  pneumonia  in  chil- 
dren, giving  the  most  minute  details  of  the  hydriatric  procedures,  their 
exact  temperature,  duration,  etc. 

Another  illustration  of  the  damage  inflicted  upon  patients  and 
upon  the  progress  and  acceptance  of  hydrotherapy,  may  be  drawn  from 
the  following  incident : 

In  February,  1889,  I  presented  before  the  New  York  Medical 
Society  the  first  plea  for  the  Brand  method  of  bathing  in  typhoid  fever, 
which  had  never  before  been  discussed  in  any  English-speaking  society. 
That  it  was  received  not  only  without  approbation  but  with  decided 
condemnation  did  not  surprise  me,  for  on  the  day  preceding  this  nieet- 

*Archiv  filr  Kinderheilkunde,  p.  13,  1891. 


THE   HYDRIATRIC   PRESCRIPTION.  511 

ing  a  now  eminent  teacher  of  medicine  had  informed  me  that  he  never 
intended  to  use  so  heroic  a  remedy,  because  he  had  seen  the  able  visit- 
ing physician  of  the  hospital  in  which  he  had  served  as  an  interne 
"  kill  a  patient"  by  this  treatment.  Inquiry  into  the  cause  of  his 
antipathy  elicited  the  fact  that  this  so-called  Brand  bath  consisted  in 
wrapping  the  patient  in  a  sheet,  placing  her  on  a  Kibbee  cot,  and  sprin- 
kling her  with  ice-water  until  the  mouth  temperature  showed  marked 
lowering.  A  brilliant  young  man,  a  teacher  and  hospital  attendant, 
was  thus  bitterly  prejudiced  against  a  method  of  bathing,  of  which,  as 
the  sequel  proved,  neither  he  nor  his  justly  eminent  teacher  really 
knew  anything.  Both  regarded  the  lowering  of  temperature  as  the 
chief  aim  of  the  cold  bath,  and  looked  upon  any  mode  of  applying  cold 
water  as  a  Brand  bath,  losing  sight  of  the  difference  in  effect  arising 
from  a  difference  in  technique.  To  wrap  the  patient  in  a  sheet  and 
sprinkle  him  with  ice  water,  as  was  done  in  the  case  cited  above,  is  a 
deviation  from  the  correct  technique  of  the  typhoid-fever  bath.  Such 
a  procedure  does  not  fulfil  its  main  object.  After  the  first  shock  has 
passed  no  opportunity  is  given  for  reaction,  because  the  sprinkling  of 
ice  water  continues;  the  cutaneous  vessels  and  the  elastic  tissue  of  the 
true  skin  contract,  as  evidenced  by  cutis  anserina;  the  extreme  cold 
imparted  by  the  wet  sheet  without  remission  maintains  the  contraction 
of  the  cutaneous  vessels,  benumbs  the  sensory  nerves,  and  thus  im- 
pedes the  transmission  of  the  shock  and  subsequent  stimulus,  even  if 
the  latter  has  ensued  in  an  exceptionally  strong  individual.  The  ab- 
sence of  friction  in  this  faulty  technique  (which  in  the  Brand  bath 
stimulates  to  reaction,  and  by  widening  the  blood  area  of  the  skin 
cools  a  large  quantity  of  blood  and  relieves  the  laboring  heart)  frus- 
trates completely  the  true  aim  of  the  cold  bath. 

The  surface  temperature  is  indeed  reduced  by  this  improper  method, 
but  the  blood  is  driven  to  the  interior,  congestions  are  favored,  the 
organs  are  overloaded,  and  the  patient  emerges  from  such  a  bath  (save 
the  mark!)  a  shivering,  cyanosed  weakling. 

Even  such  a  sheet  bath  as  was  used  by  the  distinguished  hospital 
attendant  referred  to  could,  by  proper  understanding  of  the  rationale, 
be  made  to  serve  a  useful  purpose.  Nerve  stimulus  rather  than  tem- 
perature reduction  should  be  the  object.  If  the  sprinkling  were  done 
rapidly  with  water  at  not  less  than  60°,  if  each  part  sprinkled  were  thor- 
oughly rubbed  with  the  flat  hand  of  an  attendant  until  warm,  and  thus 
every  part  of  the  body  sprinkled,  rubbed,  slapped,  and  warmed  up 
until  it  no  longer,  responded  by  warming  up,  the  dangerous  contraction 
of  the  cutaneous  vessels  would  be  obviated,  the  vasodilators  would  be 
stimulated,  a  reaction  would  take  place  whose  transmission  to  the 
brain  would  be  salutary  (see  Sheet  BatJi). 


512        THE  PRINCIPLES  AND  PRACTICE  OF   HYDEOTHERAPY. 

That  the  false  procedure  above  quoted  proved  fatal  is  due  to  an 
error  in  technique,  based  upon  a  misconception  of  the  rationale  of  the 
cold  bath  in  typhoid  fever. 

The  incident  is  referred  to  in  detail,  for  the  purpose  of  "pointing 
a  moral "  and  impressing  thereby  a  useful  lesson. 

I  am  happy  to  state  that  both  preceptor  and  pupil  *  have  learned 
to  practise  the  Brand  method  with  success.  They  have  mastered  the 
technique  and  follow  it  closely  with  rare  exceptions. 

That  the  best  judgment  must  be  applied  to  the  technique  of  this 
treatment  very  soon  becomes  apparent  to  the  observant  practitioner. 
The  ideal  results  obtained  by  Brand  and  others  in  twelve  hundred 
cases  bathed  before  the  fifth  day  without  mortality  can  be  realized  only 
by  following  the  exact  technique  of  Brand.  V.  Ziemssen  testifies  that 
whenever  he  deviated  from  the  strict  Brand  method  he  had  cause  to 
regret  it,  and  my  own  observation  in  consultation  cases  which  are  seen 
too  late  corroborates  his  experience. 

These  incidents  may  suffice  to  show  that  even  eminent  clinical 
teachers  have  failed  to  obtain  ideal  results,  because  they  deviated  from 
the  ideal  technique,  each  one  modifying  it  to  suit  his  own  fancy,  with- 
out actual  experience  with  the  better  methods.  That  physicians  must 
blindly  follow  the  dictum  of  Brand  or  of  any  other  is  not  demanded, 
but  the  Brand  method,  which  is  definite  in  its  technique,  must  not  be 
charged  with  failures  attending  its  modification,  any  more  than  Berg- 
mann's  aseptic  surgical  technique  should  be  charged  with  failures  attend- 
ing the  neglect  of  any  one  of  its  exacting  demands.  For  instance,  the 
physician  who  does  not  begin  bathing  before  the  diagnosis  is  positively 
confirmed  by  the  roseola  cannot  expect  that  freedom  from  lethal  com- 
plications which  early  bathing  surely  brings,  though  he  bathe  exactly 
according  to  Brand  throughout  the  case.  He  will  surely  have  a  smaller 
mortality  than  another  who  begins  regularly  in  the  second  or  third 
week,  or  one  who  uses  higher  body  temperatures  as  indications  for  the 

*This  gentleman  said  in  a  letter  to  the  author,  dated  December  9th,  1895: 
"  When  I  commenced  my  service  at  the  hospital  the  1st  o*  last  August,  I  had 
had  no  experience  with  the  Brand  bath  in  typhoid  fever,  and  I  am  free  to  con- 
fess that  I  was  prejudiced  against  it.  Since  that  time  I  have  had  fifty-two 
cases  of  typhoid  fever  under  my  care  in  the  hospital.  Eight-tenths  of  these 
cases  at  least  I  have  given  Brand  treatment.  I  am  now  a  believer  in  it.  I  be- 
lieve the  temperature  of  the  first  bath  should  be  higher  than  ordinarily  given, 
ray  70°  or  80°,  and  lower  in  each  subsequent  bath,  until,  say,  after  a  half-dozen 
they  will  stand  a  temperature  of  60°  or  65°."  It  may  be  added  that  a  temper- 
ature below  65°  F.  is  a  deviation  from  the  Brand  method,  which  has  proved 
serious  in  the  cases  cited,  and  that  this  teacher  abandoned  it  and  became  one 
of  the  enthusiastic  advocates  of  the  Brand  bath. 


THE   HYDRIATRIC   PRESCRIPTION.  513 

bath,  or  one  who  adopts  higher  temperatures  to  please  the  patieut  or 
Ms  friends. 

The  best  results  can  be  obtained  only  by  minute  attention  to  all  the 
details  of  the  method. 

I  have  availed  myself  of  this  illustration  of  the  subject,  because 
extensive  observation  and  careful  inquiry  among  practitioners  in  Ger- 
many and  in  this  country  have  convinced  me  that  the  lack  of  appreciation 
of  the  therapeutic  value  of  this  method  of  bathing  and  its  consequent 
feeble  recognition  by  the  profession  may  be  ascribed  to  losing  sight  of 
the  true  principles  of  the  Brand  baths,  and  consequent  too  liberal 
deviation  from  its  correct  technique.  The  latter  is  doubtless  the  cause 
of  the  desuetude  of  the  Brand  bath  in  Germany,  where  the  justly  great 
authority  of  Curschmanhas  inveighed  against  it  "  because  the  tempera- 
ture— 50°  to  60°  F. — is  dangerous."  Brand  never  ordered  bath  temper- 
ature lower  than  65°  (15°  R.). 

Physicians  always  insist  upon  exact  dosage  of  medicinal  agents,  the 
exact  time  and  mode  of  their  administration,  frequency  of  repetition, 
and  even  their  exact  preparation.  I  plead  for  the  adoption  of  similar 
care  and  attention  in  the  prescription  of  water  as  a  remedy  as  the  only 
means  of  preventing  the  future  desuetude  of  hydrotherapy. 

Precision  in  technique  is  quite  as  important  in  the  treatment  of 
chronic  diseases  as  in  the  acute.  That  the  medical  profession  has  not 
yet  accepted  this  idea  is  illustrated  by  the  prescription  blanks  of  a  cer- 
tain hydrotherapeutic  establishment,  which  read,  "  Give  the  bearer  a 
douche,  wet  pack,  sulphur  bath,  etc.  The  physician  may  strike  out 
the  bath  not  wanted. "  One  may  as  well  write  a  prescription  reading, 
"  Give  the  patient  a  dose  of  quinine,  morphine,  or  sulphonal,"  without 
specifying  exact  dose  and  mode  of  administration.  Such  a  prescrip- 
tion would  be  regarded  as  incomplete,  indeed  as  absurd.  That  a 
prescription  for  a  bath  or  other  hydriatric  procedure  without  exact 
statement  of  temperature,  duration,  mechanical  impact,  and  method  is 
equally  incomplete,  needs  but  to  be  pointed  out. 

In  a  large  hospital  which  boasts  of  a  hydrotherapeutic  department, 
prescriptions  are  often  sent  to  the  doucher,  a  man  of  no  medical 
knowledge  whatever,  reading  as  follows :  "  Give  this  man  a  douche  " 
— temperature,  duration,  and  other  details  being  left  entirely  to  the 
discretion  (?)  of  this  man.  Among  the  prescriptions  of  a  large  private 
institution  the  "  hot  box  and  Cliarcot  douche  "  is  a  favorite  with  a  cer- 
tain justly  eminent  man.  The  duration  of  the  hot  box,  which  can  be 
prolonged  until  the  patient  faints  without  immediate  harm,  the  pres- 
sure, temperature,  and  duration  of  the  Charcot  douche,  whether  the 
latter  is  to  attack  the  spinal  region  or  the  entire  back — these  details 
are  entirely  left  to  the  judgment  of  non-medical  attendants. 
33 


514       THE  PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

The  import  of  temperature  and  duration  and  mechanical  impact  of 
every  hydriatric  procedure  requires  to  be  impressed  with  emphasis. 
Every  physician  realizes  the  difference  of  effect  arising  from  different 
temperatures,  and  yet  we  commonly  read  directions  for  cold  baths, 
tepid  baths,  hot  baths.  By  a  cold  bath  is  commonly  understood  a  bath 
to  which  no  hot  water  has  been  added.  Such  a  bath  in  New  York  City, 
as  has  been  shown,  would  be  45°  F.  in  midwinter  and  75°  in  midsum- 
mer, as  ascertained  by  exact  observations  in  the  Hydriatric  Institute. 
That  thirty  degrees  would  produce  an  enormous  difference  in  effect 
goes  without  saying.  And  yet  the  exact  temperature  of  a  bath  is 
rarely  designated.  The  difference  of  effect  in  the  duration  of  a  bath 
is  also  readily  recognized,  but  that  friction  during  the  bath  or  a  pres- 
sure of  thirty  pounds  would  produce  an  entirely  different  result  from 
a  pressure  of  five  pounds  needs  to  be  practically*  observed  to  be  fully 
appreciated. 

Just  as  the  Brand  bath  has  failed  in  the  hands  of  those  who  modi- 
fied or  changed  its  technique,  so  has  hydrotherapy  in  chronic  cases  failed 
because  of  inexact  technique.  It  cannot  be  sufficiently  reiterated  that 
temperature,  pressure,  duration,  and  method  should  be  prescribed  and 
practised  with  as  much  exactness  as  the  dose,  prescription,  and  method 
of  administration  are  stated  in  prescriptions  of  medicinal  agents. 

Phthisis  may  be  offered  as  an  illustration.  The  technique  in  this 
disease  has  been  described  (page  413).  If  this  careful  technique  be 
not  observed,  if  the  patient  be  subjected  to  lower  temperatures  or  higher 
pressures  in  the  beginning,  his  reactive  capacity  would  not  be  equal  to 
the  demand  and  the  result  would  be  serious  and  discouraging.  A 
young  hydrotherapist,  recently  returned  from  Germany,  expressed 
great  surprise  that  a  case  of  phthisis  which  had  been  under  hygienic 
treatment  and  diet,  improving  and  gaining  weight  steadily,  had  begun 
to  lose  weight  after  douches  had  been  used  one  week.  To  her  question 
as  to  the  probable  cause  of  this  result,  I  replied  that  there  was  "  some- 
thing wrong  with  the  hydrotherapy  used  in  the  case."  Upon  asking 
her  to  detail  the  technique,  she  said  that  she  had  followed  the  plan 
adopted  at  the  Montefiore  Home — to  dilate  the  cutaneous  vessels  by  a 
hot-air  bath  before  applying  the  douche.  When  she  was  asked  how 
long  the  patient  remained  in  the  hot-air  bath,  the  reply  was  "  until  she 
perspired  freely. "  Here  was  the  defect  of  the  technique.  The  object 
of  the  hot-air  bath  in  phthisis  and  other  diseases  manifesting  defective 
nutrition  and  a  tendency  to  emaciation  is  to  dilate  the  cutaneous  vessels 
for  the  purpose  of  enchancing  reaction,  but  not  to  promote  tissue  change, 

*  See  "  The  Practical  Application  of  Hydrotherapy, "  a  clinical  lecture 
delivered  at  the  German  Hospital,  Philadelphia,  by  Simon  Baruch,  M.D.,  p. 
203,  International  Clinics,  July,  1897. 


THE   HYDRIATRIC   PRESCRIPTION.  515 

which  is  evidenced  by  excessive  rise  of  temperature  and  perspira- 
tion. As  the  latter  method  is  adopted  in  treating  obesity,  its  inappro- 
priateness  in  phthisis  is  at  once  apparent.  Bearing  in  mind  the  feeble 
circulation  in  phthisical  patients,  a  gradual  training  of  their  reactive 
power,  a  daily  neuro-vascular  discipline  as  it  were,  is  demanded,  and 
not  a  reduction  of  flesh  and  vitality. 

The  following  example  of  faulty  hydrotherapy  may  also  be  instruc- 
tive. From  a  published  lecture  on  neurasthenia,  delivered  by  an  emi- 
nent teacher,  the  following  is  quoted :  "  The  cold-water  treatment  in 
the  morning  is  apt  to  bring  about  a  very  beneficial  change.  I  will 
suggest  various  methods  of  applying  the  treatment,  which  you  can  use 
in  all  cases,  rich  or  poor,  old  or  young.  The  top  of  the  head  and  the 
nape  of  the  neck  are  points  of  attack.  Have  the  bathtub  one-third 
full  of  lukewarm  water  so  that  the  patient  may  stand  in  it  without  get- 
ting chilled ;  then  if  the  bath  has  a  douche  attached,  you  may  allow 
the  shower  to  play  on  the  top  of  the  head  and  then  down  the  nape  of 
the  neck ;  or  you  can  slap  the  nape  of  the  neck  and  the  spine  with 
towels  wrung  out  of  very  cold  water ;  or  let  him  take  a  large  sponge 
dipped  in  cold  water,  put  it  on  the  top  of  his  head,  and  let  the  cold 
water  run  down  his  back.  Nothing  produces  so  good  an  effect  on  the 
nervous  system  as  the  trickling  of  cold  water;  it  is  not  so  good  simply 
to  wash  with  cold  water;  trickling  out  of  a  sponge  is  the  proper  way 
to  apply  cold  water." 

The  indefiniteness  of  this  technique  is  apparent,  and  may  serve  as  a 
lesson  of  "  how  not  to  do  it. "  According  to  the  locality  jn  which  cold 
water  is  administered,  its  temperature  may  be  40°  in  midwinter  or  80° 
in  midsummer.  And  yet  this  lecturer  says  not  a  word  about  tempera- 
ture. The  trickling  of  cold  water  over  the  body  needs  but  to  be  men- 
tioned to  provoke  a  feeling  of  chilliness ;  playing  a  douche  of  cold 
water  over  the  head  and  spine  of  a  neurasthenic  of  the  excitable  type 
would  set  him  wild,  while  the  same  treatment  may  benefit  the  depressed 
neurasthenic  if  it  be  brief  and  daily  and  gradually  lowered. 

The  recklessness  of  these  suggested  modes  of  applying  cold  water 
becomes  more  glaring  when  compared  with  the  same  lecturer's  direc- 
tions for  the  use  of  strychnine  and  phosphorus.  He  is  quite  explicit 
with  regard  to  the  preparation,  dose,  and  combinations  of  these  reme- 
dies. If  he  had  followed  the  same  course  in  describing  the  water  treat- 
ment, by  stating  the  temperature  of  cold  water  and  of  the  very  cold 
water ;  the  pressure  of  the  douche,  which  from  the  height  of  a  few  feet 
is  a  chilling  drizzle,  while  from  a  height  of  fifty  or  sixty  feet  it  stings 
and  arouses  the  vasomotor  nerves  to  an  intense  and  pleasant  activity ; 
the  duration  of  the  treatment,  which,  if  left  to  the  patient,  often  bears 
unhappy  consequences ;  he  would  not  have  failed  to  reach  the  proper 


516         THE   PRINCIPLES   AND   PRACTICE   OF   HYDRO-THERAPY. 

method.  I  am  glad  to  say  that  this  teacher  has  recently  published  a 
valuable  work,  in  which  the  directions  for  hydrotherapy  are  quite 
precise  and  well  considered,  and  which  testifies  that  the  propaganda  for 
scientific  (i.e.,  exact)  hydrotherapy  is  bearing  rich  fruit. 

Another  eminent  teacher  advises  neurasthenics  to  plunge  into  a  tub 
of  warm  water  (temperature  not  being  stated),  then  allow  cold  water  to 
run  into  the  tub  until  the  water  surrounding  the  patient  is  cool ;  this 
temperature  again  being  left  to  the  judgment  or  caprice  of  the  patient. 
Here  the  very  common  error  is  committed  to  obviate  shock.  This  is 
the  baseless  dread  of  inexperienced  prescribers  of  cold  water,  who  dis- 
regard the  fact  that  the  reaction  following  the  shock  is  the  aim  of 
hydrotherapy  when  applied  as  a  tonic  or  as  a  nerve  stimulus,  and  that 
the  reaction  is  exactly  in  proportion  to  the  preceding  shock. 

It  is  unhappily  a  very  prevalent  error  to  regard  the  most  agreeable 
bath  as  the  most  salutary.  We  do  not  so  reason  in  the  application  of 
medicinal  agents,  of  electricity,  or  of  diet.  And  yet  the  application 
of  water  may  be  made  agreeable  by  gradually  accustoming  the  patient 
to  lower  temperatures,  slowly  reducing  them  every  day  or  two,  making 
the  application  brief  at  first  and  increasing  or  decreasing  the  duration 
and  pressure  day  by  day.  The  prime  essential,  however,  should  always 
be  borne  in  mind  that  reaction  is  our  aim,  that  this  cannot  be  evoked  with- 
out some  "shock,"  that  the  more  intensely  the  latter  can  be  borne  the 
more  effective  the  reaction ;  but  the  more  brief  it  is,  the  less  unpleasant. 

If  the  physician  bears  in  mind  that  his  object  in  treating  a  case  is 
an  increase  of  the  quantity  of  blood  circulating  in  the  cutaneous  ves- 
sels, an  enhancement  of  the  nutrition,  a  stimulus  to  the  entire  nervous 
system,  he  will  endeavor  so  to  order  the  technique,  provided  he  has 
mastered  its  details,  as  to  evoke  this  salutary  reaction  without  ex- 
cessive shock. 

For  the  attainment  of  satisfactory  and  definite  results  in  hydro- 
therapy,  a  correct  prescription  is  therefore  paramount.  This  cannot 
be  too  often  and  too  earnestly  impressed  upon  the  profession.  Acute 
diseases,  like  typhoid  fever  and  pneumonia,  are  under  constant  observa- 
tion of  the  physician,  who  may  at  once  note  the  result  of  an  improper 
hyclriatric  technique  and  modify  it,  or,  as  is  unfortunately  more  often 
done,  relinquish  it  altogether.  In  chronic  cases  much  damage  may  be 
done  before  the  physician  discovers  it,  if  the  treatment  be  not  in  the 
hands  of  trained  and  intelligent  attendants  who  are  under  medical 
supervision.  Too  often  the  details  are  left  to  laymen  because  physicians 
have  not  received  instruction  in  the  rationale  and  technique.  The 
result  is  as  Dr.  Vogl,  medical  director  of  the  Bavarian  army,  *  says : 
u  Physicians  are  themselves  to  blame  if  hydrotherapy  is  chiefly  practised 

*Mlinchener  Medicinische  Woclienschrift,  No.  27,  1896. 


THE   HYDRIATRIC   PRESCRIPTION.  517 

by  laymen  who  know  as  little  of  the  disease  they  are  treating  as  they  do 
of  the  effect  of  water,  and  thus  damage  not  only  the  patients  who  confide 
in  them,  but  also  the  cause  of  hydrotherapy." 

During  a  visit  to  twenty-five  institutions  in  Germany  and  France 
in  which  hydrotherapy  is  practised  largely,  I  was  astonished  and  cha- 
grined to  find  only  four  which  had  a  stationary  thermometer  to  indi- 
cate the  temperature  of  douches,  and  only  two  which  had  gauges  in 
use  to  indicate  the  pressure  applied.  The  technique  cannot  be  con- 
trolled with  any  degree  of  certainty  without  these  accurate  aids. 
Nevertheless,  good  results  are  obtained,  because  in  most  of  these  insti- 
tutions the  treatment  is  administered  under  the  eyes  of  experienced 
physicians. 

To  avoid  injurious  shock  and  gradually  educate  the  patient's  reac- 
tive capacity  should  be  our  guide  in  the  hydriatric  prescription.  To 
enable  me  to  accomplish  this  end  with  precision  I  have,  without  neglect- 
ing other  hydriatic  procedures,  resorted  to  douches,  with  which  I  am 
able  to  grade  the  temperature,  duration,  and  pressure,  and  thus  adapt 
the  shock  and  reaction  to  the  patient's  capacity  and  endurance,  and 
to  note  the  result  definitely  every  day.  Thus  we  may  proceed  with 
intelligence  and  judgment  in  meeting  the  indications  of  each  case,  by 
changing  the  procedure  or  by  increasing  or  diminishing  temperature, 
duration,  and  pressure  accurately  from  day  to  day. 

Conclusion. — The  reason  that  different  results  are  obtained  by  differ- 
ent physicians  from  the  application  of  water  may  be  found  in  the  tech- 
nical errors  committed  on  account  of  an  erroneous  conception  of  the 
rationale  of  hydrotherapy.  To  avoid  this  rock  upon  which  many  have 
split,  the  reader  will  do  well  carefully  to  study  not  only  the  technique, 
but  the  rationale  of  each  procedure,  and  use  a  definite  prescription  for 
applying  it. 

The  clinical  histories  have  been  related  chiefly  to  emphasize  the 
manner  in  which  the  technique  may  be  changed  to  adapt  it  to  varying 
conditions,  and  to  enable  physicians  to  write  distinct  and  positive  direc- 
tions for  the  nurse,  who  should  be  watched.  If  this  cannot  be  done  it 
were  far  more  wise  to  refrain  from  this  treatment  unless  a  physician 
who  has  cultivated  this  special  field  can  be  reached  to  take  charge  of 
the  case. 

Obstinate  cases  of  nervous,  gastric,  pulmonary,  cardiac  disease  are 
constantly  referred  for  treatment  to  specialists  in  these  branches  by 
the  family  physician,  even  when  the  diagnosis  is  not  in  question. 
The  same  course  may  be  followed  with  advantage  to  patient  and  doctor 
alike  when  other  remedial  agents  fail,  by  resorting  to  specialists  in 
hydrotherapy,  through  which,  as  the  celebrated  Naples  clinician  Sem- 
mola  has  written,  "  frequently  real  marvels  of  restoration  in  severe 
and  desperate  cases  have  been  obtained." 


CHAPTER  XXX. 

HISTORICAL  EPITOME— THE  LESSON— NECESSITY  FOR  INSTRUC 
TION  IN  HYDROTHERAPY. 

THE  history  of  hydrotherapy  forms  the  most  interesting  chapter  of 
the  history  of  medicine ;  it  illustrates  how  prejudice  may  thwart  prog- 
ress and  how  enlightened  physiology  and  pathology  have  tended  to 
reinstate  a  valuable  but  neglected  remedy. 

What  remedies  have  survived  since  the  days  of  Hippocrates  and 
Galen?  The  application  of  diet  and  the  use  of  water  are  really  the 
only  remedies  which  have  withstood  the  test  of  time.  Blood-letting 
may  be  cited  to  illustrate  the  fate  of  a  remedial  agent  which  has  no 
rational  basis.  This  heroic  measure  has  for  centuries  been  advocated 
and  defended  by  the  leaders  of  medical  thought  and  practised  by  the 
rank  and  file  of  the  profession.  Nevertheless,  the  last  third  of  the 
nineteenth  century  witnessed  its  complete  downfall  from  a  position 
which  no  other  therapeutic  agent  has  ever  occupied.  As  soon  as  the 
progress  of  physiology  and  pathology  gave  the  physician  a  clearer 
insight  into  the  vital  processes  in  health  and  disease,  blood-letting  lost 
its  prestige  beyond  recovery.  Water,  whose  origin  as  a  remedy  is 
coeval  with  blood-letting,  but  which  has  never  attained  such  mar- 
vellous dominance  over  the  medical  mind,  enjoys  to-day  greater  confi- 
dence and  is  more  genuinely  appreciated  than  at  any  previous  time. 
Despite  professional  and  lay  prejudice,  it  stands  to-day  secure  against 
successful  assault,  by  reason  of  its  rational  basis  and  favorable  bedside 
results. * 

A  rapid  glance  over  the  history  of  hydrotherapy  suffices  to  show 
that  water  is  an  orthodox  remedy,  having  been  first  dilated  upon  in 
the  works  of  Hippocrates,  who  correctly  insisted  that  cold  stimulates 
and  warmth  relaxes,  and  who  applied  it  in  many  diseases  with  skill 
and  judgment. 

Among  the  noted  men  who  warmly  advocated  water  in  disease  may 
be  mentioned  Asclepiades,  whose  eminence  is  attested  by  his  being  the 
friend  and  physician  of  Cicero.  He  really  foreshadowed  "  the  cellular 
theory"  by  teaching  that  not  the  juices  of  the  body  but  its  elements 
and  atoms  are  active  in  health,  and  that  a  disturbance  of  their  activity 
*  "System  of  Practical  Therapeutics,  "  H-are,  vol.  i. 


HISTORICAL   EPITOME.  519 

constitutes  the  essence  of  disease. "  He  cast  aside  all  spoliative  medica- 
tion and  depended  chiefly  on  diet,  exercise,  and  baths.  Celsus, 
Themison,  Ccelius  Aurelianus,  and  Antonius  Musa  were  his  disciples, 
all  men  who  occupy  high  places  in  the  history  of  medicine.  Celsus 
was  the  physician  of  Ovid  and  Fabius  Maximus.  Musa  restored  the 
Emperor  Augustus  and  the  poet  Horace  to  health  by  cold  baths  (Sue- 
tonius). The  philosopher  Seneca  became  an  enthusiastic  "psychro- 
lutus,"  after  he  was  cured  by  cold  water  prescribed  by  Charmis. 

The  greatest  physician  of  the  seventh  and  eighth  centuries,  Paulus 
^gineta,  was  an  active  hydrotherapist;  he  applied  cold  affusions  in 
sunstroke  and  anuria. 

In  the  twelfth  century  Van  der  Heyden  collated  three  hundred  and 
sixty  cases  of  malignant  dysentery  cured  by  water.  Van  Helmont 
regarded  baths  and  affusions  as  superior  to  medicines. 

In  1697  great  propaganda  for  hydrotherapy  was  made  by  Floyer, 
a  learned  English  physician,  whose  book  was  translated  into  German, 
and  converted  Prof.  Friedrich  Hoffmann.  Being  regarded  as  the  most 
able  physician  in  Germany,  the  latter  diffused  the  knowledge  thus 
obtained  and  elaborated  by  him  over  all  parts  of  Europe. 

The  body  physician  of  Frederick  the  Great,  Theden,  treated  small- 
pox, malignant  fevers,  and  rheumatism  with  water. 

In  1743  Hahn  taught  its  value  in  small-pox  and  other  exanthemata. 
That  justly  great  physician,  Hufland,  was  so  warm  an  advocate  of 
hydrotherapy  that  he  offered  a  prize  for  the  best  treatise  on  the  action 
of  cold  water  in  fever,  the  prize  being  obtained  by  Professor  Froehlich, 
physician  to  the  Austrian  emperor. 

Despite  the  advocacy  of  these  and  other  eminent  men,  water  did 
not  attain  popularity  until  Priessnitz  came  upon  the  scene.  This 
remarkable  empiric  was  so  successful  that  he  treated  in  1840  nearly 
sixteen  hundred  patients  from  all  parts  of  the  world.  Many  physicians 
from  foreign  lands  visited  this  peasant  water  doctor,  and  became  mis- 
sionaries of  hydrotherapy. 

In  Germany  his  followers  were  mostly  laymen.  Nevertheless,  the 
impress  of  his  life  and  work  can  be  noticed  to-day.* 

Germany  has  been  a  fruitful  field  of  research  and  practical  demon- 
stration in  hydrotherapy,  in  recent  times  as  well  as  in  the  past. 

The  founder  of  homoeopathy  (Hahnemann)  appears  to  have  pos- 
sessed correct  views  on  hydrotherap}'.  He  wrote :  "  If  there  be  a  uni- 
versally useful  remedy,  Avater  must  be  one."  After  describing  his 
method  of  treating  old  ulcers  of  the  leg  by  cold  foot  and  general  baths, 
he  dilated  judiciously  upon  inexactness  of  application  as  follows : 
"  The  degree  of  temperature  of  each  bath  and  the  movement  in  it  must 
*The  "Priessnitz  Uraschlag  "  is  a  reminder  of  this  influence. 


520       THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

be  adapted  to  the  improvement  in  strength;  the  weakest  body  may 
thus  reach  the  strongest  bath,  if  the  exact  prescription  of  the  doctor 
be  followed  with  punctual  obedience."  "I  have  never  ceased  to  won- 
der how  our  greatest  physicians  could  be  so  negligent  in  their  prescrip- 
tion of  the  cold  bath.  They  order  half  baths  or  full  baths  morning 
and  evening,  and  this  is  their  idea  of  a  prescription.  Of  the  degree  of 
cold,  the  exact  duration  of  the  bath,  and  other  indispensable  points 
not  a  word.  Surprise  at  the  frequently  reported  ill  effects  of  such  cold 
baths  must  cease  when  these  mutilated,  inexact,  three-syllabled  pre- 
scriptions produce  results  quite  opposite  to  those  aimed  at."  This 
sound  criticism  may  be  justly  applied  to  the  present  generation  of 
physicians,  who  would  add  vastly  to  their  efficiency  by  heeding  the 
advice  of  this  eccentric  but  evidently  observant  man. 

To  Prof.  Wilhelm  Winteruitz,  who  graces  the  chair  of  hydrother- 
apy  in  Vienna,  medical  science  owes  nearly  all  it  has  learned  about 
the  scientific  uses  of  water  in  disease.  He  dedicated  himself  to  the 
development  of  hydrotherapy  in  his  graduation  thesis,  which  concluded 
with  the  hope  that  "the  knowledge  of  the  uses  of  water  in  disease 
would  become  the  common  property  of  medical  men."  Before  his  time 
there  existed  no  physiological  basis  for  hydrotherapy.  He  infused  the 
true  scientific  spirit  into  its  study  and  pursuit,  and  built  upon  this  foun- 
dation the  noble  edifice  upon  which  medical  men  may  now  rely  in  the 
hour  of  direst  need.  The  most  important  truth  of  hydrotherapy,  its 
primary  action  upon  the  nervous  system,  was  clearly  brought  out  by 
Winternitz,  who  showed  that  even  in  fevers  this  effect  is  paramount 
and  the  antithermic  effect  is  secondary.  As  a  teacher,  his  genial  man- 
ner and  clear  presentation  have  conveyed  the  knowledge  of  the  value 
of  water  in  disease  to  students  from  every  land,  who  have  become  mis- 
sionaries of  his  good  work.  Physicians  and  nurses  are  sent  to  him 
for  instruction  from  the  Bavarian  and  Austrian  armies.  Winternitz 
has  published  over  two  hundred  monographs  and  works,  which,  hav- 
ing been  translated  into  every  language,  serve  everywhere  as  beacon 
lights  to  the  searcher  after  truth.  As  a  practitioner  his  wonderful 
success  is  illustrated  by  the  institution  at  Kaltenleutgeben,  which  has 
increased  from  eighteen  patients  in  1862  to  two  thousand  patients  in 
1896.  He  created  the  first  hydrotherapeutic  clinic  (a  part  of  the 
Allgemeine  Universitats  Klinik  in  Vienna)  at  his  own  expense.  When 
the  introduction  of  antitoxic  therapeusis  threatened  the  disparagement 
of  hydrotherapy,  as  of  all  other  therapeusis,  this  grand  man,  fortified 
by  physiological,  pathological,  and  therapeutic  learning,  clearly  set 
forth  the  scientific  truth  that,  while  water  possessed  no  antitoxic  vir- 
tues, it  aided  nature  in  its  battle  against  the  manifestations  of  toxaemia, 
by  improving  cardiac  action,  vivifying  the  nervous  system,  and  further- 


HISTORICAL   EPITOME.  521 

ing  the  oxidation  and  elimination  of  toxic  products,  thus  establishing 
more  firmly  than  hitherto  the  scientific  basis  of  hydrotherapy.  This 
doctrine  he  had  taught  years  ago,  but  its  acceptance  was  slow ;  it  is 
now  almost  universally  accepted. 

The  application  of  cold  water  became  one  of  the  methods  in  the 
modern  expectant  treatment  of  acute  diseases.  The  greatest  progress 
in  this  direction  was  initiated  by  Ernst  Brand,  who,  in  1861,  published 
his  remarkable  results  from  baths  of  65°  F.  in  typhoid  fever.  The 
methodical  use  of  these  baths  has  become  classical,  and  will  probably 
remain  so  until  specific  antitoxic  methods  are  discovered.  Jurgen- 
sen,  Traube,  Liebermeister,  Fiirbringer,  Leyden,  Ziemssen,  Strumpell, 
Filehne,  Naunyn,  von  Merhig,  Senator,  Goldscheider,  Leyden,  Cursch- 
man,  of  the  present  generation,  favor  active  hydrotherapy  in  febrile  dis- 
eases, and  place  it  at  the  head  of  all  remedial  agents,  but  unfortunately 
they  have  not  given  the  Brand  bath  a  fair  trial.  This  is  the  most  painful 
incident  in  the  history  of  hydrotherapy.  Despite  the  fact  that  in  the 
eighth  decade  of  the  last  century  the  most  accurate  statistics  and  bed- 
side observations  in  the  most  reliable  hospitals  (army)  of  the  world 
had  affirmed  the  life-saving  value  of  the  Brand  bath  in  typhoid  fever, 
and  despite  the  further  fact  that  these  statistics  were  vouched  for  by 
the  Imperial  Statistical  Bureau  in  Berlin  over  the  signature  of  Profes- 
sor Guttstadt,  the  German  teachers  did  not  subject  this  method  to  a 
fair  (if  any)  trial  in  the  civil  hospitals  and  condemned  it  as  barbaric, 
heroic,  or  otherwise  reprehensible  without  actual  trial  (see  Curschman's 
condemnation  in  Nothna gel's  cyclopaedia).  Condemnation  of  reform- 
ers in  medicine  and  their  persecution  has  not,  alas,  been  rare  in  the 
history  of  our  calling.  Harvey  was  driven  out  of  London,  Semmel- 
weiss  was  driven  to  a  lunatic  asylum,  and  our  own  gentle  Oliver  Wen- 
dell Holmes  was  ridiculed  by  the  "  professors  of  the  great  schools  in 
Philadelphia."  Brand,  after  positive  demonstration  of  the  life-saving 
value  of  his  bath,  was  simply  treated  with  contempt  and,  like  the  great 
Harvey,  obtained  vindication  in  foreign  lands  (France  and  the  United 
States).  The  author  shall  always  regards  as  his  best  achievement  the 
introduction  of  the  Brand  bath  to  his  colleagues,  and  he  is  proud  of 
the  spirit  of  fairness  with  which  American  physicians  gave  it  practi- 
cal trial  (page  192). 

On  its  value  in  chronic  diseases  we  have  the  testimony  of  many 
teachers,  among  whom  is  Prof.  F.  A.  Hoffman,  of  Leipzig,  who  says :  * 
"  Cold  water  is  a  therapeutic  agent  by  whose  correct  application  we 
may  most  surely  and  without  danger  of  reaction  exercise  and  invig- 
orate the  nervous  system,  and  herein  I  seek  its  fundamental  signifi- 
cance in  the  treatment  of  all  possible  internal  diseases.  I  am  convinced 
*  "  Allgemeine  Therapie,"  Leipzig,  1892. 


522        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

that  in  time  all  chronic  diseases  of  the  organs  will  be  drawn  into  the 
domain  of  the  bath  treatment." 

For  many  decades  Winternitz  had  stood  alone  in  Europe  valiantly 
battling  for  instruction  in  hydrotherapy.  Erb,  Charcot,  and  Semmola 
practised  and  advocated  it  in  their  respective  countries;  they  did  not 
teach  the  technique,  for  the  simple  reason  that  they  had  not  been 
taught  this  most  important  subject.  They  sent  their  patients  to  spe- 
cialists in  hydrotherapy.  The  latter  continued  to  exist  precariously 
in  a  commercial  sort  of  manner;  it  was  aptly  named  by  Winternitz 
"the  stepchild  of  medicine."  Suddenly  there  came  a  great  revulsion. 
The  reason  thereof  was  the  rise  of  the  Naturdrzte  of  whom  Father  Kneipp 
was  the  most  prominent  exponent.  When  the  author  visited  Germany 
in  1890  he  found  magnificent  institutions,  like  the  Zimmerman  at  Chem- 
nitz, drawing  large  clienteles.  The  enormous  inroads  made  by  these 
empirics  upon  the  income  and  status  of  the  medical  profession  was 
creating  great  alarm,  as  is  evidenced  by  the  plea  of  Professor  Crede  * 
insisting  upon  the  necessity  of  applying  hydrotherapy  and  other  physi- 
cal remedies  in  the  hospitals,  and  pleading  for  instruction  in  these 
branches  in  the  universities.  He  claimed  with  clear  discernment  that 
"  if  physicians  were  better  versed  in  these  branches,  the  field  of  operation 
of  many  quacks  would  be  greatly  curtailed." 

The  serious  inroads  of  these  empirics  upon  the  interests  of  the 
medical  profession  led  to  the  appointment  of  a  "  commission  for  the 
revision  of  medical  examinations,"  of  which  that  eminent  and  practi- 
cal teacher,  Professor  Kussmaul,  acted  as  chairman.  His  report  f 
clearly  set  forth  the  alarming  conditions  which  were  existing  and  be- 
coming more  acute  constantly,  and  suggested  the  remedy  as  follows : 
"  It  cannot  be  denied  that  the  faith  in  prescriptions  is  waning  among 
educated  people,  and  that  confidence  in  dietetic  remedial  methods  and 
in  the  curative  power  of  water  is  in  the  ascendant. 

"  Even  the  lower  strata  begin  to  realize  how  much  may  be  accom- 
plished with  air,  water,  and  proper  regulation  of  habits  of  life  without 
the  use  of  medicine.  A  distrust  against  even  the  most  powerful  and 
indispensable  medicinal  agents  is  becoming  more  pronounced  in  large 
circles.  Water  is  the  chief  agent,  which  has  won  steadily  growing 
confidence  as  a  remedy,  because,  unlike  every  other,  it  may  be  utilized 
in  varied  and  changing  temperatures  and  forms  of  application,  for  the 
most  varied  therapeutic  purposes.  According  to  the  correct  and  skil- 
ful selection  of  the  procedure,  it  regulates  the  circulation  and  distribu- 
tion of  blood,  the  production  of  heat  and  tissue  change,  and  influences 
the  respiration  and  the  nerves. 

*  Berliner  klinische  Wochenschrif  t,  26,  1895. 
t  Deutsche  med.  Wochenschrif  t,  1896. 


HISTORICAL   EPITOME.  523 

"The  treatment  by  water  has  passed  its  childhood  days,  when  it 
still  staggered  upon  feeble  limbs,  and  not  infrequently  did  as  much 
damage  as  is  done  by  improper  medication.  Ripened  experience  and 
physiological  knowledge  have  fortified  the  treatment  and  rendered  it 
safe.  Hydrotherapy,  combined  with  diet,  may  undoubtedly  bring 
about,  or  aid  in,  the  cure  of  numberless  acute  and  chronic  diseases. 

"  Of  hydrotherapy  the  young  physician  knows  almost  nothing  when 
he  leaves  the  university.  Unfortunately  he  sooner  or  later  may  en- 
counter discomfiture  when  an  uneducated  water  doctor  steps  in  and 
cures  the  patient  after  he  has  failed.  Deeply  chagrined  and  disap- 
pointed in  his  confidence  in  scientific  therapeutics,  he  may  pass  into 
the  camp  of  crude  empiricism. 

"Here  lies  a  great  gap  in  the  education  of  our  physicians;  here 
lies  the  real  cause  of  weakness  in  the  contest  for  the  favor  of  the 
public  which  sooner  or  later  must  be  encountered  by  the  physician  with 
the  layman  who  may  have  gotten  experience  in  water  treatment  or  be 
naturally  adapted  for  it.  A  revision  of  our  course  of  study  must  be 
made  above  all  things." 

The  effect  of  this  vigorous  arraignment  of  the  whole  profession  for 
neglect  of  the  most  important  remedial  agents  was  magical.  Clinics 
were  erected  in  Berlin,  Leipzig,  Heidelberg,  Breslau,  Jena,  and  other 
schools;  teachers  made  pilgrimages  to  Vienna,  where  the  high  priest  of 
hydrotherapy  had  for  years  wearily  preached  the  same  doctrine.  As 
a  result  of  this  response  to  a  crying  need,  physical  remedies  obtained 
more  recognition. 

To-day  not  alone  do  most  medical  schools  on  the  Continent  teach 
hydrotherapy,  but  the  interest  of  this  subject  has  awakened  a  literary 
activity  in  the  special  lines  of  physical  therapeutics,  of  which  hydro- 
therapy  is  the  chief.  A  number  of  special  journals  are  now  published, 
of  which  the  Zeitschrift  fur  physikalische  und  didtetische  Therapie, 
by  Leyden  and  Goldscheider,  is  the  most  prominent. 

Thus  has  it  come  about  that  the  " instinct  of  self-preservation," 
that  most  potent  of  all  factors  in  life,  has  accomplished  what  Winter- 
nitz  and  a  few  earnest  and  courageous  men  had  failed  to  do. 

In  the  Balneological  Congress  held  in  Munich  in  1896,  the  chief  of 
Professor  Ley  den's  clinic,  Dr.  G.  Klemperer,  gave  a  resume  of  the 
methods  used  in  the  clinic  by  advice  and  with  the  co-operation  of 
Professor  Leyden.  He  emphasized  the  fact  that "  the  effects  of  hydro- 
therapy  are  derived  from  an  extraordinary,  quite  incomparable  excita- 
tion produced  upon  the  nervous  system,  which  is  transmitted  to  vari- 
ous organs."  In  this  address  he  dwelt  upon  its  value  in  neurasthenia, 
asthma,  functional  and  organic  cardiac,  gastric,  and  intestinal  diseases, 
which  have  been  referred  to  in  the  clinical  portions  of  this  work. 


524       THE   PRINCIPLES  AND   PRACTICE   OF   HYDROTHERAPY. 

In  Italy,  where  the  eminent  Savonarola  had  early  established  water 
as  a  remedy  by  his  work,  "  Tractatus  de  Omnibus  Italise  Balneis, "  a 
priest  damaged  its  reputation  by  senseless  enthusiasm.  Pater  Ber- 
nardo, living  in  the  island  of  Malta,  was  the  precursor  of  Kneipp,  of 
whom  so  much  is  heard  to-day.  He  practised  many  of  the  same 
methods  (walking  upon  wet  grass  and  upon  wet  stones)  and  attracted 
ah  Europe  with  his  "  miraculous  cures. "  He  was  followed  by  Todano 
and  Sangez,  in  1722.  The  former  paraded  as  "Medicus  per  aquam," 
the  latter  as  "  Medicus  per  glaciem, "  both  filling  their  credulous  patients 
with  ice  water,  and  rubbing  them  with  snow  and  ice,  while  they  fed 
them  on  three  or  four  yolks  of  eggs  a  day.  This  quackery  again 
caused  water  to  fall  into  disuse  among  physicians.  Its  value  ceased 
to  be  recognized  until  Gianini,  professor  in  Milan,  published  in  1805 
his  work,  "  Delia  Natura  delle  Febri  e  del  Migliore  Metodo  di  Curarle, " 
in  which  he  substituted  baths  of  from  five  to  fifteen  minutes  for  Carrie's 
affusions  in  fevers,  gout,  and  rheumatism.  Thus  the  empirics  caused 
an  indifference  to  the  remedial  value  of  water  to  result,  which  con- 
tinued for  eighty  years. 

Italy  was  rescued  later  from  indifference  to  hydrotherapy  by  the 
teaching  and  writings  of  many  eminent  men — Borelli,  Baglivi,  Bellini, 
Valisneri,  Cyrillo.  These,  with  Michelotti  and  Cocchi,  were  the  fore- 
runners of  men  like  Cantani,  Semmola,  and  Vinaj,  who  have  in  more 
recent  times  illustrated  the  value  of  hydrotherapy  clinically  and  physi- 
ologically., Some  of  the  most  notable  investigations  upon  the  effects 
of  hydriatric  procedures  emanate  from  Vinaj  and  Maggiora.  Semmola, 
professor  of  therapeutics  in  the  Naples  University,  whose  lectures 
(1890)  were  translated  into  German  with  a  laudatory  preface  from 
Professor  Nothnagel,  taught  that  "  hydrotherapy  stimulates  cutaneous 
activity,  and  with  it  all  functions  of  tissue  change  and  organic  purifica- 
tion, so  that  often  real  marvels  of  restoration  in  severe  and  desperate 
cases  are  accomplished.  Unfortunately  these  remarkable  results  are 
more  rare  to-day  than  they  were  in  the  time  of  Priessnitz,  of  which  I 
was  mj'self  a  witness.  The  reason  appears  to  lie  in  the  fact  that 
hydrotherapy  has  become  the  monopoly  of  the  exclusively  trade  doctors, 
who  treat  the  various  maladies  without  strict  selection  of  the  hydriatic 
procedure  in  each  case,  etc.  Hydrotherapy  presents  a  truly  rational 
treatment,  and  therefore  certain  and  unfailing  effects,  unless  the  local 
processes  have  reached  incurable  limits  (atheroma,  visceral  arterio- 
sclerosis, etc.).  In  such  cases,  indeed,  pharmacology  alone  is  also  pow- 
erless in  its  results." 

In  one  of  the  hospitals  in  Florence,  Italy,  the  author  saw  the  best 
douche  apparatus  in  Europe,  in  March,  1900. 

France, — A  general  practitioner,   Schedel,  who  studied  hydrothe- 


HISTORICAL   EPITOME.  525 

rapy  in  Germany,  was  the  first  physician  who  demonstrated  the  value 
of  cold-water  applications  in  the  building  up  of  failing  compensation 
in  valvular  diseases  of  the  heart,  and  as  a  tonic  in  tuberculosis. 

The  great  Magendie  also  increased  our  knowledge  of  the  effects  of 
water  by  physiological  demonstrations. 

Fleury  founded  a  distinct  school  of  hydrotherapy  by  the  introduc- 
tion of  douches  as  the  chief  method,  fortifying  his  clinical  results  by 
physiological  and  rational  deductions.  He  claimed  that  cold  douches 
are  a  reliable  substitute  for  quinine  in  malarial  diseases,  and  that 
they  are  of  great  value  in  tuberculosis  and  anaemia.  By  his  indefati- 
gable labors  and  physiological  demonstrations,  as  far  as  the  knowledge 
of  the  day  enabled  him,  he  gave  an  impetus  to  the  systematic  use  of 
the  douche,  which  is  to-day  recognized  as  the  French  method,  and 
which  has  become  famous  through  its  advocacy  and  application  by 
Charcot,  Dujardin-Beaumetz,  and  others. 

An  incident  occurring  in  1839  furnished  an  interesting  illustration 
of  the  status  of  hydrotherapy  in  France.  Two  regular  practitioners, 
Engel  and  Wertheim,  petitioned  the  French  government  for  permission 
to  open  a  hydropathic  institution.  The  petition  was  referred  to  the 
French  Academy  of  Medicine,  which  appointed  a  committee,  consist- 
ing of  Bouillieaud,  Velpeau,  and  Roche.  The  last-named  delivered  such 
a  tirade  against  hydrotherapy,  characterizing  it  as  "  dangerous,  unsci- 
entific, chimerical,  and  opposed  to  the  simplest  laws  of  physiology 
and  pathology, "  that  the  sixty  members  present  made  an  adverse  report. 
Permission  being  denied,  Wertheim  demanded  a  bedside  test.  Gibert 
and  Devergie  applied  hydrotherapy  in  the  Hopital  St.  Louis,  and 
reported  so  favorably  that  permission  was  granted  by  the  ministers. 
A  few  years  later  Scoutetten,  who  was  sent  to  Germany  by  Marshal 
Soult  to  study  hydrotherapy,  reported  that,  "  while  it  cannot  be  reckoned 
a  universal'  remedy,  the  numerous  permanent  cures  it  has  wrought  in 
intelligent  persons  commend  it  to  popular  attention.  The  interests 
of  humanity  and  medical  science  demand  that  a  demonstration  of  the 
technique  and  action  of  hydrotherapy  should  be  made  in  Paris  under 
the  eyes  of  able  physicians."  This  unbiassed  and  sensible  report  gave 
a  great  impetus  to  the  development  of  hydrotherapy  among  French 
physicians,  to  whose  honor  it  redounds  to-day. 

France  has  steadily  advanced  in  the  development  and  practical 
application  of  hydrotherapy.  The  great  clinician  Charcot  applied 
it  constantly  in  his  practice,  and  doubtless  owed  much  of  his  remark- 
able success  to  the  judicious  use  of  water.  He  was  in  the  habit  of 
referring  his  cases  to  Keller  in  Paris,  and  to  the  hydrotherapeutic 
establishments  of  Divon  and  other  rural  resorts.  In  acute  diseases  the 
missionary  labors  of  Glenard,  who  learned  the  Brand  method  while  a 


526         THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

prisoner  of  war  at  Stettin,  and  of  his  fellow  townsmen,  Tripier  and 
Bouveret,  who  have  written  an  excellent  treatise  which  has  been  trans- 
lated into  the  German  language  by  Pollak,  are  noteworthy.  The 
scientific  investigations  of  Eoque,  Weil,  and  A.  Eobin,  on  the  effect  of 
the  cold  bath  upon  urinary  excretion  in  typhoid  fever,  have  become 
classical.  To-day  France  is  the  stronghold  of  the  Brand  method. 
Hutinel,  Guinon,  Eendu,  Johel-Eenoy,  and  others,  have  emphasized 
the  value  of  bathing  in  pneumonia  and  the  exanthemata.  "  A  prophet 
is  not  without  honor  save  in  his  own  country. " 

The  works  of  Dujardin-Beaumetz,  Delmas,  Duval,  Beni-Barde, 
Glatz,  and  Charcot  afford  evidence  of  great  activity  on  the  part  of 
modern  French  physicians  in  hydrotherapy  for  chronic  diseases. 

Water-cure  establishments  did  not  until  recently  multiply  in  France 
as  they  did  in  Germany  after  Priessnitz,  because  the  laws  against  lay 
practice  are  more  stringent  in  France.  This  fact  has  caused  a  marked 
difference  in  the  development  of  water  institutions  in  these  two  coun- 
tries. Physicians  of  scientific  attainment  entered  upon  the  investiga- 
tion of  hydrotherapy  in  France  with  zeal,  while  in  Germany  the  natural 
prejudice  entertained  by  the  medical  profession  against  the  empiricism 
of  Priessnitz  and  his  followers  for  a  long  time  prevented  educated 
physicians  from  attaching  themselves  to  water  establishments.  To-day 
the  pendulum  seems  to  have  swung  in  the  opposite  direction,  judging 
from  the  number  of  medical  men  who  claim  to  be  followers  of  the 
priestly  water  apostle,  Kneipp.  The  "  Naturarzt "  is  more  or  less  pro- 
tected in  Germany,  where  he  practises  his  crude  art  of  healing  un- 
molested, while  in  France  the  medical  profession  is  protected  against 
these  charlatans. 

In  England  hydrotherapy  has  not  obtained  a  foothold  among  physi- 
cians, despite  the  fact  that  some  of  our  best  works  on  the  subject 
emanated  from  English  authors  in  the  latter  part  of  the  eighteenth  and 
early  part  of  the  nineteenth  centuries. 

That  English  physicians  are  not  at  the  present  time  better 
acquainted  with  the  methods  of  Floyer,  Currie,  and  Wright  in  the 
treatment  of  fevers  is  a  deplorable  fact,  illustrating  their  neglect  of 
medical  history  and  inattention  to  the  medical  achievements  of  men 
whose  labors  were  better  appreciated  in  foreign  lands. 

Currie' s  work  was  translated  into  several  foreign  languages,  and 
his  practice  was  introduced  into  the  Vienna  hospitals  by  Joseph  Frank. 
Currie  introduced  affusions  in  the  treatment  of  fevers,  and  this  really 
pointed  the  way  to  the  Brand  method.  In  gout  and  convulsions,  pa- 
ralysis and  tetanus,  and  other  diseases  he  also  claims  to  have  had  good 
results. 

A  careful  search  for  the  cause  of  the  desuetude  into  which  the  use 


HISTORICAL  EPITOME.  527 

of  water  has  fallen  in  England,  despite  its  advocacy  by  its  most  emi- 
nent medical  men  in  the  seventeenth  century,  develops  the  fact  that 
Floy  er'  s  writings  were  so  enthusiastic  and  convincing  that  many  intel- 
ligent lay  people  espoused  the  methods  advocated  by  him.  Among 
these  was  a  minister  of  the  gospel,  John  Hancocke,  who  in  1723  wrote 
"Febrifugum  Magnum,  or  Common  Water  the  Best  Cure  for  Fevers," 
which  reached  seven  editions  in  one  year.  The  enormous  influence  of 
this  work  upon  the  lay  people  is  explained  by  the  popularity  of  his 
book.  With  natural  aversion,  English  physicians  neglected  a  remedy 
which  had  thus  been  lauded  into  popularity.  Even  such  influential 
men  as  Pitcairne,  Cheyne,  and  Huxham,  who  appreciated  and  advo- 
cated its  use,  could  not  establish  a  permanent  position  for  it.  As  a 
result  this  valuable  remedy,  especially  in  its  application  to  chronic 
diseases,  fell  into  the  hands  of  irregulars,  who  erected  hydropathy  into 
a  system  of  treatment  and  still  more  decidedly  estranged  regular  prac- 
titioners from  water  as  a  remedy.  The  practice  and  writings  of  Drs. 
Wilson  and  Gull,  of  Malvern,  in  more  recent  times,  may  be  cited  to 
confirm  this  statement. 

Many  years  of  active  and  careful  propaganda  will  be  required  to 
regain  the  ground  that  was  lost  through  the  bitter  ppposition  aroused 
by  the  writings  of  John  Hancocke  and  his  ilk. 

It  is  a  sad  commentary  upon  the  indifference  to  the  history  of  medi- 
cine to  note  the  neglect  of  scientific  hydrotherapy,  even  in  acute  dis- 
eases, which  exists  in  England  to-day.  In  the  summer  of  1896  the 
author  visited  one  of  the  largeest  and  most  modern  hospitals  in  Lon- 
don. Making  the  rounds  with  the  able  and  otherwise  progressive 
physician,  a  case  of  typhoid  was  reached,  which  was  receiving  expec- 
tant treatment.  When  I  asked  if  the  Brand  method  or  any  positive 
water  treatment  was  used  besides  sponging,  the  attendant  exclaimed, 
"Do  you  approve  of  such  heroic  measures?" 

Tn  a  discussion  of  the  treatment  of  fevers  in  1895  by  the  British 
Medical  Society,  a  general  condemnation  was  meted  out  to  cold  baths, 
because  "  they  are  heroic. "  Only  one  timid  advocate  was  heard  in  their 
favor.  But  Prof.  William  Osier,  of  Baltimore,  stated  on  that  occasion 
that  "  were  the  Brand  method  more  heroic  still  he  would  use  it,  be- 
cause it  saves  life."  This  incident  occurred  in  the  country  which  gave 
birth  to,  and  in  which  lived  and  practised  James  Currie,  whose  writ- 
ings had  inspired  Brand! 

When  the  author  requested  the  editor  of  a  prominent  British  medi- 
cal journal  to  publish  a  plea  for  the  more  general  application  of  water 
in  disease,  in  February,  1900,  this  gentleman  protested  that  such  a  plea 
was  not  necessary,  because  the  British  literature  on  this  subject  was 
abundant.  In  order  to  convince  this  editor,  the  author  requested  the 


528        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

librarian  of  one  of  the  largest  medical  libraries  in  London  to  furnish 
him  the  titles  of  all  articles  and  works  on  pure  hydrotherapy,  writ- 
ten by  physicians  during  the  past  quarter  of  a  century.  The  number 
of  this  literary  treasure  reached  eleven !  It  is  gratifying  to  the  author 
to  state  that  since  the  publication  of  his  "  plea  "  in  the  Medical  Press 
and  Circular  of  London,  the  attention  of  practitioners  has  been  directed 
to  this  valuable  agent,  and  frequent  reference  to  its  use  is  now  found 
in  English  literature. 

In  America  the  application  of  water  in  disease  has  until  recent 
times  been  vague,  and  its  advocacy  rather  timid,  probably  because  the 
earlier  text-books  on  medicine  were  reproductions  of  works  by  English 
physicians,  who,  as  I  have  shown  above,  have  exhibited  a  singular 
indifference  to  hydrotherapy.  The  most  earnest  non-empirical  advo- 
cates of  water  in  disease  in  America  prior  to  the  author's  propaganda 
were  Drs.  Abram  and  Mary  Putnam  Jacobi,  of  New  York,  and  the 
late  Hiram  Corson,  of  Pennsylvania,  who  illustrated  its  value  in  a 
large  clientele,  and  to  whose  writings  I  owe  my  earliest  inspiration  and 
example. 

During  the  past  two  decades  quite  a  change  has  been  wrought  in 
the  attitude  of  American  physicians  toward  hydrotherapy. 

Dr.  W.  H.  Draper,  professor  of  clinical  medicine,  Columbia  Uni- 
versity, in  an  address*  on  hydrotherapy  before  the  New  York  Academy 
of  Medicine,  said :  "  In  persons  whose  nutrition  has  been  enfeebled  by 
chronic  disease,  and  in  neurasthenia,  hysteria,  and  hypochondriasis, 
its  good  effects  are  very  striking.  It  seems  to  be  more  effective  than 
any  treatment  by  medicine  in  stimulating  the  nerve  centres,  in  restor- 
ing the  equilibrium  of  the  circulation,  and  in  reviving  the  activity  of 
the  organic  functions." 

In  February,  1889,  I  presented  before  the  New  York  State  Medical 
Society  the  first  plea  made  in  this  country  for  the  cold  (Brand)  bath 
in  typhoid  fever.  It  received  only  condemnation  in  the  discussion 
which  followed.  In  commenting  upon  this  paper,  the  Medical  Record 
of  February  16th,  1889,  said  editorially :  "  It  will  be  difficult  to  per- 
suade the  profession  to  adopt  the  heroic  method  of  cold  bathing." 

These  discouragements  were  offset  by  the  request  from  Dr.  Austin 
Flint,  in  charge  of  the  first  division  of  Bellevue  Hospital,  to  explain 
the  technique  of  the  Brand  bath  to  his  staff.  And  it  was  at  once 
adopted  by  him  and  brilliantly  continued  by  Peabody,  Ball,  and 
James,  in  their  clinics  and  lectures.  In  1890  I  read  a  paper  in 
the  New  York  Academy  of  Medicine,  a  report  of  which,  published  in 
The  Medical  Record,  stated  that  "Dr.  Alfred  Loomis  said  he  would 
take  the  first  opportunity  of  giving  this  method  a  trial,"  and  "Dr. 

*  Medical  Record,  April  22d,  1893. 


HISTORICAL   EPITOME.  529 

Delafield  said  that  he  had  had  no  real  experience  with  the  Brand 
bath."  Both  of  these  teachers  began  to  teach  this  method  at  once,  as 
I  learned  from  reliable  members  of  their  classes.  That  their  teaching 
had  fallen  on  fruitful  soil  is  evident  from  the  fact  that  in  1902  Dr. 
Oilman  Thomson's  text- book  on  practice  stated  that  "the  mortality 
from  typhoid  fever  in  the  New  York  and  in  the  Presbyterian  Hospital 
had  been  reduced  from  sixteen  to  six  per  cent  by  the  Brand  bath." 
And  in  1903  the  late  Dr.  H.  P.  Loomis  reported  to  the  Practitioners' 
Society  that  "  the  mortality  from  typhoid  fever  in  the  New  York  hospi- 
tals had  been  reduced  fifty  per  cent  by  the  systematic  use  of  the 
Brand  bath."  * 

Inasmuch  as  the  mortality  from  this  disease  from  1878  to  1883  in 
the  New  York  hospitals  had  been  calculated  by  Dr.  Delafield  to  be  in 
1,300  cases  24.66  per  cent,  it  is  evident  that  the  Brand  bath  had  saved 
about  one  thousand  lives  in  the  hospitals  of  New  York  alone  during 
the  past  fifteen  years.  Since  the  method  may  be  more  perfect  in 
private  practice,  the  saving  of  life  would  seem  enormous.  That  this 
was  the  result  of  instruction  in  hydrotherapy  of  typhoid  fever  "  goes 
without  saying." 

The  Brand  method  is  at  the  present  time  practised  in  the  best  hos- 
pitals of  this  country.  I  am  able  to  make  this  statement  positively, 
because  I  have  addressed  letters  of  inquiry  regarding  their  present  at- 
titude toward  the  Brand  bath  to  the  most  prominent  clinicians,  and 
the  replies  are  unanimous  in  the  same  vein  as  the  following  just  re- 
ceived from  the  professor  of  practice  in  Columbia  University  and  phy- 
sician to  the  Roosevelt,  Bellevue,  and  other  hospitals :  "  In  reply  to 
your  favor  of  the  13th  I  beg  to  say  that  I  am  continually  using  the 
Brand  treatment  in  typhoid  fever  and  still  regard  it  as  of  the  utmost 
value.  My  views  as  to  its  efficiency  have  not  changed  in  the  past  few 
-years.  I  remember  very  well  your  introduction  of  the  method,  and 
that  we  are  indebted  to  you  for  many  earnest  and  valuable  contribu- 
tions upon  it,  and  especially  for  your  emphasis  on  the  necessity  for 
using  it  thoroughly."  How  different  is  the  response  to  a  similar  in- 
quiry ("  Umfrage  ")  sent  out  by  the  "  Deutsche  Klinik  "  in  the  summer 
of  1907 !  Only  one  of  these  professors  in  Germany  referred  to  the 
bath,  and  he  condemned  it  as  barbarous.  A  practitioner  who  had  the 
temerity  to  intrude  himself  into  this  august  symposium  stated  that  he 
had  personally  witnessed  the  brilliant  results  of  Brand  in  the  Franco- 
Prussian  War,  but  he  had  abandoned  it  because  it  did  seem  so  barbarous. 
Was  ever  maudlin  sympathy  more  flagrant!  The  German — Brand — 
has  been  vindicated  by  American  physicians,  history  has  repeated 
itself!  The  Brand  bath  has  been  demonstrated  as  the  most  valuable 

*  Medical  Record,  January  10th,  1903. 
34 


530       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

method  in  typhoid  fever  by  the  German  Army  surgeons  and  later  by 
the  enormous  statistics  of  Medical  Director  Vogl,  of  the  Miinchner 
Garrison  Hospital,  where  over  eight  thousand  cases  were  recorded  dur- 
ing forty  years  under  all  the  prevailing  methods  of  treatment.  The 
lowest  mortality  was  from  the  strict  Brand  bath,  2. 7  per  cent ;  the 
highest  mortality  was  from  the  expectant  treatment,  20.7  per  cent. 
What  the  mortality  of  typhoid  fever  is  in  the  hospitals  from  which  the 
"Umfrage"  was  answered  does  not  appear;  these  professors  simply 
give  their  "  views "  without  corroborative  evidence.  The  American 
professors  offer  not  only  their  views  but  furnish  clinical  proof  of  their 
correctness. 

Hydrotherapy  is  now  regularly  practised  in  many  of  our  metropol- 
itan hospitals  in  acute  diseases. 

The  author  introduced  its  systematic  application  for  chronic  diseases 
in  the  Montefiore  Home  for  Chronic  Invalids  in  1887.  Many  other 
institutions  have  since  that  time  had  douche  apparatuses  constructed, 
and  are  applying  water  successfully  in  chronic  diseases.  The  results 
have  been  most  favorable  in  lunatic  asylums,  because  in  these  institu- 
tions it  is  applied  systematically  and  with  precision.  See  Chap. 
XXVIII.  Thus  an  epoch  in  hydrotherapy  has  been  inaugurated,  which 
is  unique  in  the  history  of  this  subject. 

Other  evidences  of  awakened  interest  in  the  subject  have  been  else- 
where referred  to. 

Many  American  health  resorts  and  sanatoria  practise  hydrotherapy 
in  the  old-fashioned  hydropathic  manner.  Recently  the  German 
practice  of  attaching  hydrotherapeutic  establishments  to  good  hotels 
at  health  resorts  has  been  initiated  in  this  country.  The  Lake  wood 
Hotel  (winter)  in  New  Jersey,  the  "  Mecklenburg "  of  Chase  City, 
Va. ,  the  Homestead  at  Hot  Springs,  the  Palm  Beach  Hotel  in  Florida, 
and  the  Hotel  El  Paso  de  Eobles  in  California  have  obtained  complete . 
hydrotherapeutic  equipments,  which  are  superior  in  efficiency  for  the 
correct  application  of  temperature,  duration,  and  pressure,  to  those 
which  the  writer  has  seen  in  Germany  or  France,  and  which  are  under 
the  direction  of  educated  physicians. 

The  author  has  established  a  hydriatric  department  in  the  River- 
side Baths,  to  which  many  physicians  and  dispensaries*  send  obstinate 
cases  for  treatment,  the  attendance  at  which  has  increased  from  2,146 

*  To  facilitate  the  utilization  of  hydrotherapy,  the  author  has  devised  a  pre- 
scription blank  for  dispensary  and  other  physicians,  stating  name,  diagnosis, 
and  treatment  desired,  whether  tonic,  useful  in  anaemia,  chlorosis,  neurasthenia, 
and  other  affections  depending  upon  defective  haematosis  and  nutrition;  alter- 
ative, useful  in  rheumatism,  gout,  diabetes,  and  other  diseases  depending  on  de- 
fective tissue  change;  or  cleansing.  The  treatment  is  executed  by  the  attendants 
trained  by  the  author,  and  is  reported  to  the  physician  in  charge. 


HISTORICAL  EPITOME.  531 

in  1895  to  16,012  in  1902 — incontrovertible  evidence  of  the  increasing 
appreciation  of  the  value  of  hydrotherapy.  Bellevue  Hospital  has 
also  followed  this  initiative.  The  Park  Avenue  Hydriatric  Institute 
of  this  city,  which  was  inaugurated  in  1892  for  the  purpose  of 
promoting  the  use  of  hydrotherapy  in  chronic  diseases,  has  admin- 
istered over  100,000  treatments  to  patients  referred  by  over  one  hun- 
dred physicians.  It  is  to  be  hoped  that  such  institutions  may  multiply 
in  our  cities,  and  that  they  may  always  be  under  the  direction  of  edu- 
cated physicians,  and  not  be  "  run  "  by  masseurs  and  bath  nurses,  who 
have  so  often  brought  hydrotherapy  into  disrepute  among  physicians. 

These  evidences  of  growing  appreciation  of  the  merits  of  hydro- 
therapy  among  American  physicians  offer  to  the  author  a  gratifying 
finale  to  this  brief  historical  resume  of  the  subject. 

Conclusion. — An  unbiassed  study  of  the  entire  history  of  hydrother- 
apy develops  the  fact  that  the  great  clinical  teachers  of  the  present 
day  reaffirm  their  faith  in  a  method  of  treatment  which  has  received 
the  highest  sanction  from  Hippocrates,  Asclepiades,  Celsus,  Hufeland, 
and  Currie.  For  a  long  period  the  medical  profession  had  received  its 
chief  information  on  water  from  men  who,  though  honestly  striving 
for  the  propaganda  of  water  as  a  remedy,  were  regarded  as  enthusiasts 
whose  views  were  probably  tinged  by  prejudice  in  favor  of  their  meth- 
ods of  practice.  Some  faint  shadows  of  the  bitter  but  just  preju- 
dice which  Priessnitz  and  Hancocke  and  their  ignorant  and  blatant 
followers  had  aroused  in  the  minds  of  medical  men  still  seem  to  fall 
upon  those  who  attempt  to  secure  attention  to  hydrotherapy.  To 
remove  this  fallacious  and  mischievous  idea  is  one  of  the  aims  of  this 
work. 

The  testimony  of  clinical  observers,  not  connected  with  hydrotherapy 
as  a  specialty,  has  therefore  been  cited  to  define  clearly  its  status  at 
the  present  time,  as  evidenced  in  the  clinical  portions  of  this  work. 

History  has  repeated  itself  here  as  in  other  departments.  The 
opinions  of  the  most  judicious,  philosophical,  and  successful  physicians 
of  past  ages  have  been  sustained  by  the  judgment  of  this  enlightened  era. 

The  student  of  the  history  of  hydrotherapy  must  observe  that  it 
has  passed  through  many  cycles  in  the  estimation  of  physicians.  It 
would  be  profitable  to  ascertain  the  causes  of  these  fluctuations  in  order 
to  avoid  their  adverse  influence  in  the  future. 

Just  as  among  the  ancients  we  find  among  the  most  renowned  phy- 
sicians the  most  active  advocates  of  water  as  a  remedy,  so  does  its  his- 
tory in  modern  times  develop  the  same  fact.  The  simplicity  of  this 
remedy,  however,  antagonized  the  pedantic  and  self-important  mem- 
bers of  the  profession.  When  laymen,  who  must  have  learned  its 
value  from  observing  its  effects  in  the  hands  of  physicians,  espoused 


532        THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

it,  the  latter  became  entirely  estranged.  Thus  did  it  come  about  that 
Priessnitz  created  a  sect,  the  hydropaths,  whose  influence  for  the  pop- 
ularization of  the  treatment  was  in  inverse  ratio  to  its  adoption  by  the 
profession.  And  this  blighting  effect  of  the  empirical  espousal  of  water 
as  a  remedy  is  to-day  mainly  responsible  for  the  aversion  which  many 
physicians  feel  to  its  adoption.  This  aversion  is  least  pronounced  in 
France,  because  that  country  has  not  been  so  extensively  invaded  by 
the  water  quack,  and  its  hydrotherapeutic  institutions  are  under  the 
care  of  educated  physicians.  In  Germany,  too,  where  Ziemssen, 
Brand,  Jlirgensen,  Winternitz,  and  others  have  labored  to  prepare  a 
scientific  basis  for  hydrotherapy,  prejudice  is  rapidly  disappearing 
among  the  rank  and  file  of  the  medical  profession.  This  is  also  the 
case  in  Italy. 

In  England  and  America,  however,  much  agitation  will  be  required 
to  induce  physicians  to  wrest  this  valuable  therapeutic  agent  from  the 
hands  of  the  empirics,  to  whom  their  indifference  appears  to  have  dele- 
gated it.  Great  progress  has,  however,  been  made  since  the  publica- 
tion of  the  first  edition  of  this  work.  Very  recently  Dr.  J.  H.  Kel- 
logg has  published  a  large,  almost  encyclopaedic  work  on  "  Eational 
Hydrotherapy,"  which  is  exhaustive  of  every  detail  and  adds  a  brilliant 
contribution  to  American  medical  literature. 

Are  we,  as  medical  men,  just  to  ourselves  or  to  those  who  intrust 
their  lives  and  health  into  our  keeping,  in  maintaining  an  indifferent 
attitude?  Calm  reflection  must  bring  us  t'o  realize  the  fact  that  the 
application  of  water  in  disease  is  the  most  orthodox  therapeutic  measure 
in  medicine,  having  (as  I  have  shown)  been  fully  treated  by  Hippoc- 
rates, and  taught  by  the  most  eminent  and  judicious  men  who  have 
illuminated  medical  history,  and  that  therefore  hydrotherapy  deserves 
to  be  liberated  from  the  absurd  and  undeserved  stigma  of  relationship 
with  empiricism. 

The  excessive  medication,  combined  with  blood-letting,  which,  as 
referred  to  above,  characterized  the  practice  of  medicine  in  the  early 
part  of  this  century,  gave  way  to  what  was  termed  therapeutic  con- 
servatism. The  writings  of  Bigelow  and  Flint  in  this  country,  and 
of  Dietl,  Wunderlich,  and  others  in  Europe,  developed  the  expectant 
method  of  treatment,  which  aided  the  system  in  its  battle  against  dis- 
ease instead  of  fighting  the  latter  at  the  expense  of  the  former.  The 
therapeutic  nihilism  resulting  from  the  abandonment  of  excessive 
medication  causes  many  physicians,  especially  in  Germany,  to  shrug 
their  shoulders  when  discussing  treatment,  while  they  glow  with 
enthusiasm  when  the  bacteriological  or  pathological  aspect  of  the  case 
is  considered.  As  a  result  of  this  indifference  to  therapeutics,  a  sect 
of  "  nature  doctors"  (Naturarzte)  has  appeared,  who  propagate  their 
therapeutic  ideas  by  lectures,  books,  and  periodicals,  and  thus  succeed 
in  driving  the  physician  from  the  field.  The  empirics  like  Priessnitz, 


HISTORICAL   EPITOME.  533 

Hancocke,  Oertel,  Pater  Bernardo,  and  their  ilk  are  to-day  represented 
by  the  followers  of  Kneipp,  who  used  cold  water  in  the  most  crude 
methods,  and  combined  it  with  herbs  and  teas,  but  chiefly  depended 
upon  abstemiousness  in  diet  and  mode  of  life.  The  water  procedures 
of  Kneipp  are  based  upon  the  idea  that  the  body  must  be  forced  to 
produce  its  own  reaction,  a  correct  principle  if  not  indiscriminately 
applied  to  patients  whose  reactive  capacity  needs  gradual  training. 
To  neglect  of  the  latter  may  be  ascribed  the  numerous  sad  failures 
reported  by  reliable  observers,  but  never  published  by  the  Kneipp 
enthusiasts.  In  this  country  there  are  several  "  Kneipp  cures"  which 
eke  out  an  existence.  It  would  seem  that  the  practical  American 
mind  may  by  proper  instruction  be  held  aloof  from  this  fad. 

I 
THE  LESSON. 

The  study  and  judicious  application  of  hydrotherapy  in  regular 
practice  will  accomplish  more  for  the  protection  of  the  people  against 
the  quacks  than  prosecutions  through  legal  channels.  It  is  not  wise, 
however,  to  treat  the  doings  of  these  people  with  contempt  and  to  shrug 
our  shoulders  when  their  "  cures"  are  brought  to  our  attention.  The 
patient  cares  little  how  he  is  healed ;  he  certainly  prefers  to  be  cured 
by  the  empiric  to  being  kept  in  continuous  pilgrimage  to  the  scientific 
doctor's  office.  A  correct  diagnosis  does  not  interest  a  sick  man  so 

intensely  as  correct  treatment. 

ii 

NECESSITY  FOB  INSTRUCTION  IN  HYDROTHERAPY. 


The  author  hopes  to  bring  the  medical  profession  to  a  realization  of 
the  danger  which  by  reason  of  their  indifference  threatens  them  and 
their  clientele,  by  presenting  the  above  brief  resume  of  the  history  of 
water  as  a  remedy.  He  would  urge  most  earnestly  a  careful,  conscien- 
tious, and  thorough  investigation  of  its  physiological  and  clinical 
claims,  and  the  introduction  of  means  for  better  instruction  of  medical 
students  in  the  theory  and  practice  of  hydrotherapy.  Happily  some 
of  the  most  earnest  teachers  in  Germany  are  now  making  an  effort  in 
this  direction. 

The  addition  of  hydrotherapy  to  the  clinical  curriculum  has  recently 
been  agitated  in  the  German  Parliament,  and  has  culminated,  through 
the  intelligent  recognition  of  Director  of  Education  Althof,  in  the 
establishment  of  a  chair  on  hydrotherapy  in  the  Berlin  University,  to 
which  Professor  Brieger,  the  renowned  clinician  and  bacteriologist,  has 
been  assigned. 

The  medical  director  of  the  Bavarian  army,  Dr.  A.  Vogl,  has  re- 
cently *  recommended  the  instruction  of  medical  officers  of  the  army 
in  hydrotherapy,  and  has  induced  his  government  to  send  a  number  of 
*  Miinchener  medicinische  Wochenschrift,  No.  27.  1896. 


534       THE   PRINCIPLES   AND   PRACTICE   OF   HYDROTHERAPY. 

army  surgeons  to  the  Hydrotherapeutic  Clinic  of  Professor  Winternitz, 
in  Vienna,  for  this  purpose. 

Vogl  regards  "  the  insufficient  education  of  medical  men  in  physical 
therapeutics,  especially  in  hydrotherapy,  as  a  serious  defect,  which 
injures  physicians  in  their  earlier  practice,  and  for  which  it  is  difficult 
to  compensate  later."  He  justly  holds  that  "hydrotherapy  should  be 
taught  in  its  entirety,  as  Winternitz  has  done,  upon  a  physiological 
basis.  By  lectures  and  clinical  demonstrations  it  should  be  brought 
before  the  student  just  as  other  therapeutic  agents  and  methods  are 
offered  to  him — as  obligatory  branches  of  study.  When  this  is  done, 
hydrotherapy  will  become  the  general  property  of  all  physicians,  and 
not  be  practised  as  a  special  and  distinct  method." 

"Here  lies  a  great  gap  in  the  education  of  our  physicians;  here  lies 
the  real  cause  of  weakness  in  the  contest  for  the  favor  of  the  public 
which  sooner  or  later  must  be  encountered  by  the  physician  with  the 
layman  who  may  have  gotten  experience  in  water  treatment  or  be 
naturally  adapted  for  it.  A  revision  of  our  course  of  study  must  be 
made,  above  all  things. 

"  The  teacher  of  clinical  medicine  has  now  so  many  duties  to  perform 
in  his  work  of  instruction  that  no  time  is  at  his  disposal  for  familiariz- 
ing his  students  with  hydrotherapy.  In  order  to  instruct  them  more 
than  superficially,  distinct  chairs  and  clinical  divisions  are  required, 
in  which  appropriate  cases  may  be  treated  by  hydrotherapeutic  proce- 
dures. These  lectures  could  be  combined  with  others  on  balneology  and 
purely  dietetic  treatment,  but,  for  Heaven's  sake,  let  not  this  professor- 
ship be  connected  with  that  on  pharmacology!" 

As  has  been  referred  to  above,  this  clear  presentation  of  facts  has 
inaugurated  an  epoch  in  medical  teaching  in  Germany.  The  humane 
and  scientific  spirit  of  the  medical  profession  was  sustained  by  that 
most  potent  of  all  influences  on  human  action — the  law  of  self-preser- 
vation. 

In  this  connection  the  views  of  Professor  Vierordt,  of  the  Heidel- 
berg University,  are  of  great  interest,  as  showing  that  the  seed  which 
Winternitz  many  years  ago  sowed  is  now  about  to  reach  fruition  in 
his  own  country.  Vierordt  says :  "  All  signs  indicate  that  hydrotherapy 
will  succeed  in  obtaining  a  distinct  and  clear  position  in  medical  science, 
and  that  it  will  correspondingly  reach  the  consideration  in  medical 
instruction  to  which  it  is  entitled.  Hydrotherapy  can  be  taught  only 
practically,  because  it  must  be  applied  more  individually  than  any 
other  therapeutic  agent." 

*  "  Ueber  den  commissarischea  Entwurf  zur  Revision  der  deutschen  medi- 
zinischen  Prilf ungsordnung, "  1896. 


HISTORICAL,   EPITOME.  535 

Professor  Vierordt*  has  established  an  arrangement  for  baths, 
douches,  massage,  etc.,  in  connection  with  his  polyclinic,  where  trained 
attendants  apply  them  under  strict  medical  supervision  with  regard  to 
temperature,  duration,  and  force.  One  of  his  assistants  resides  near 
the  institution  and  watches  over  its  work.  "  All  expectations  have  been 
amply  fulfilled.  It  is  utilized  for  instruction  of  small  groups  of  students 
in  the  polyclinic,  who  thus  learn  practically,  under  the  personal  super- 
vision of  the  professor  and  his  assistants,  the  indications  for  and 
application  of  the  more  simple  and  useful  hydriatric  methods.  Experi- 
ence gathered  in  this  small  institution  warrants  the  recommendation 
that  facilities  for  ambulant  hydriatic  treatment  should  be  connected  with 
every  medical  polyclinic,  for  the  benefit  of  patients  and  students  alike. 
Hydrotherapy  should  be  included  in  medical  instruction,  not  as  a  spe- 
cialty ;  it  should  be  brought  completely  into  the  domain  of  our  scien- 
tific curative  agencies  by  the  careful  selection  of  procedures  and  of 
cases  to  which  it  is  adapted. " 

In  Leipsic  Professor  Windscheid  and  in  Cologne  Professor  Mathes 
teach  hydrotherapy. 

In  Dresden  Professor  Crede  f  also  insists  upon  the  necessity  of  ap- 
plying hydrotherapy  and  other  physical  remedies  in  the  hospitals. 

In  Berlin  in  connection  with  Prof  essorBrieger's  chair  of  therapeu- 
tics, a  hydrotherapeutic  institute  has  been  built  on  the  Charite' 
grounds,  where,  during  a  recent  visit  by  the  author,  he  saw  large 
numbers  of  German,  Swiss,  Austrian,  Russian,  and  Japanese  physicians 
attending  the  clinics. 

From  recent  correspondence  with  Professor  Brieger  it  appears  that 
this  clinic  has  been  enlarged  twice  by  reason  of  the  increased  number 
of  students.  In  a  recent  letter  Professor  Brieger  writes :  "  I  rejoice 
that  hydrotherapy  is,  under  your  guidance,  gaining  ground  in  America, 
and  that  it  may  soon  become  the  common  property  of  physicians  as  it 
is  with  us." 

In  America  also  a  plea  for  instruction  in  hydrotherapy  has  been 
published.  Dr.  Frederick  Peterson,  chief  of  the  Neurological  Clinic 
in  the  College  of  Physicians  and  Surgeons,  Columbia  University, 
wrote :  J  "  Many  of  the  scientific  principles  of  hydrotherapy  have 
already  been  established,  but  it  would  be  well  worth  while  to  carry  out 
at  a  few  of  our  clinics  and  in  the  physiological  laboratories  some  of  the 
elaborate  experiments  with  water  which  are  frequently  resorted  to  for 
the  purpose  of  demonstrating  the  uses  of  new  drugs.  It  would  be  well 
if  some  of  our  large  schools  would  initiate  a  course  of  lectures  on  this 

*  Deutsche  medicinische  Wochenschrift,  1897. 

f  Berliner  klinische  Wochenschrift,  26,  1895. 

\  American  Journal  of  the  Medical  Sciences,  February,  1893. 


536       THE   PRINCIPLES  AND  PRACTICE  OF   HYDROTHERAPY. 

subject."     This  plea  of  a  justly  eminent  alienist,  like  those  of  the 
author,  remained  unheeded  for  ten  years. 

With  regard  to  the  teaching  of  hydrotherapy  in  our  schools,  it  is 
unnecessary  to  add  anything  to  the  pleadings  of  recognized  teachers, 
with  whose  views  the  author  is  in  entire  accord.  My  personal  inter- 
course with  many  physicians  affords  daily  illustration  of  the  truth  of 
their  statements  and  the  correctness  of  their  views.  I  would  most 
earnestly  commend  to  the  consideration  of  the  faculties  of  our  progres- 
sive medical  schools  the  example  of  the  Universities  of  Vienna, 
Heidelberg,  Berlin,  Jena,  and  Leipsic. 

Much  time  that  is  now  wasted  in  teaching  the  properties  and  ap- 
plication of  drugs,  which  are  rarely  used  in  practice,  could  be  profit- 
ably devoted  to  the  clinical  study  of  the  action  of  the  most  powerful 
remedial  agent.  In  view  of  the  importance  of  the  branch,  the  course 
adopted  by  Columbia  University,  which  makes  hydrotherapy  an  obliga- 
tory study  in  its  clinics  and  lectures,  is  worthy  of  imitation.  Twenty 
years  ago  the  Dean  of  the  faculty  of  the  University,  who  was  urged  by 
one  of  its  most  eminent  professors  to  add  hydrotherapy  to  its  curricu- 
lum, regretted  that  this  course  was  impossible  because  the  curriculum 
was  overcrowded.  It  seems  that  by  proper  pruning  of  the  latter  the 
chair  of  hydrotherapy  has  been  made  possible  under  the  present 
administration.  A  hydrotherapeutic  institute,  equipped  with  hot-air 
boxes  and  a  douche-table  elsewhere  illustrated,  and  other  facilities 
for  the  administration  of  water  in  chronic  diseases  have  been  added. 

The  senior  class,  divided  into  sections  of  ten  or  more,  receives 
clinical  instruction  in  the  hydrotherapeutic  department  of  the  Vander- 
bilt  Clinic  on  Monday  and  Friday  afternoons.  The  first  half  of  the 
clinic  is  devoted  to  demonstration  of  cases,  the  diagnosis  is  briefly 
dwelt  upon,  and  the  pathology  and  etiology  are  referred  to  with  a  view 
to  point  out  the  therapeutic  indications.  The  aid  of  hydriatric  meas- 
ures and  the  reason  for  their  employment,  with  or  without  drugs,  in 
the  concrete  case  are  clearly  gone  into,  and  the  patient  is  treated  in  the 
presence  of  the  students,  who  are  encouraged  to  ask  explanations  of 
any  obscure  points.  The  latter  half  of  the  clinic  is  devoted  to  demon- 
stration of  the  technique  of  hydriatric  procedures,  and  students  are 
requested  to  practise  them  just  as  they  are  taught  bandaging  or  other 
manual  procedures  in  other  clinics.  The  clinic  is  under  the  charge  of 
a  chief,  and  two  assistants  who  write  the  histories,  demonstrate  pro- 
cedures, and  "quiz"  the  students.  A  trained  attendant  treats  cases 
under  their  direction  on  Mondays,  Wednesdays,  and  Fridays  from  1  to 
4  P.M.  Only  males  are  treated,  for  obvious  reasons.  Female  patients 
and  cases  not  required  for  teaching  are  referred  to  the  Riverside  Asso- 
ciation Hydriatric  Department,  which  is  under  my  direction,  and  treats 


HISTORICAL,   EPITOME.  537 

about  fifty  cases  daily.  Wednesday  afternoon  is  devoted  to  experi- 
ments in  hydrotherapy  and  instruction  of  the  clinical  staff.  A  course 
of  lectures  upon  the  principles  and  practice  of  hydrotherapy  is  also 
provided  for  during  the  latter  half  of  the  semester.  The  final  ex- 
amination includes  not  less  than  two  questions  on  hydrotherapy. 

America  stands  foremost  now  in  positively  securing  instruction  in 
the  application  of  water  in  disease  for  the  rising  generation  of  phy- 
sicians. Columbia  University  is  the  only  school  in  which  hydrother- 
apy is  made  an  obligatory  study.  The  author  cherishes  the  hope  that 
other  schools  may  follow  its  initiative  for  the  promotion  of  the  inter- 
ests of  medicine  and  the  consequent  amelioration  of  human  suffering. 


INDEX 


ABLUTION,  general,  106 

in  acute  diseases,  105 

in  chronic  diseases,  105 

therapeutics  of,  108 
Acne,  steam  in  obstinate,  312 
Affusion,  110 

in  broncho-pneumonia,  112 

in  broncho-scarlatina,  112 

in  delirium  tremens,  113 

therapeutics  of,  111 
Aix  douche,  466 

Alcohol  in  fever,  Musser  on,  210 
America,  United  States  of,    hydro- 
therapy  in,  128 
Anaemia,  diaphoresis  in,  408 

douche  in,  263 

management  of,  404 
Angina,  false,  hydrotherapy  in,  460 
Antipyretics,  danger  of,  206 

H.  A.  Hare  on,  207 
Asiatic  cholera,  372 

curable,  375 

enteroclysis  in,  290,  376 

hydrotherapy  of,  374 

hypodermoclysis  in,  374 

Vogl  on,  374 
Axillary  temperature,  fault  of,  92 

BAKLZ  on  Japanese  baths,  72 
Ball,  Dr.  A.  B.,  on  friction,  161 
Baruch,  Dr.  H.  B.,  on  blood  cells,  67 
Bath,  Burr's  portable,  167 

cold  friction,  164 

cold,  physiological  action  of,  88 

diagnostic,  321 

hot  air,  387 

hot,  physiological  effect,  94 

hot,  Rubner  on,  73,  74 

hot,  Winternitz  on,  73 

tub,  portable,  164,  165 


Bath,  warm  fun",  229 

in  chronic  rheumatism,  235 
Bed  bath,  167 
Bedsores,  steam  in,  313 
Bier,  experiments  of,  54 
Bladder,  irrigation  of,  297 

irrigation   of,  without   catheter, 
298 

Keys  on,  297 
Blanket  pack,  hot,  137 
Blood  cells,  Breitenstein  on,  65 

changes  in  density  of,  61 

effect  of  baths  on,  57 

pressure,  50 

thinning  of,  63 
Brand  bath,  early  application  of,  334 

Ball,  Prof.,  on,  196 

error  of  lowering  temperature, 
219 

friction  in,  172,  174 

Glenard  on,  198 

history  of,  in  U.  S.  A.,  528 

in  New  York  hospitals,  195 

Loomis  on,  195 

Musser  on,  194 

objections  to,  221 

Osier  on,  197 

prophylactic  effect  of,  219 

Sihler  on,  201 

Smythe  on,  193 

taken  by  physicians,  211 

technique  of,  168 

Thompson,  Oilman,  on,  203 

Tyson  on,  193 

Wilson,  J.  C-,  on,  192 
Brand  method,  reasons  for  desuetude 

in  Germany,  327 
Brand  treatment,  323 
Brieger  on  sciatica,  453 
Broadbent,  196 


540 


INDEX. 


Broncho-pneumonia,  affusion  in,  112 

baths  in,  336 
Burns,  bath  in,  244 
Burton-Opitz,  experiments  of,  61 

CATARRH,  gastric,  471 

Catarrhal  jaundice,  enteroclysis    in, 

289 

Chest  compress,  rationale  of  action, 
356 

statistics  of,  364 
Chlorosis,  management  of,  403 
Cholelithiasis,  lavage  in,  283 
Cholera,  Asiatic,  enteroclysis  in,  290, 

376 
Cold  bath,  aim  of,  211 

contraindication  to,  225 

effect  on  nervous  system,  177 

effect  on  temperature,  179 

friction  in,  172 

Hare  on,  207 

objections  to,  211 

statistics  of,  189,  203 

therapeutic  supremacy  of,  203 
Cold  coil,  head,  151 
Cold,  effect  on  muscles,  76 
Cold  friction  bath,  therapeutics  of,  187 
Cold  rub,  123 

Colonic  lavage,  Dr.  Turck  on,  287 
Compress,  abdominal,  146 

chest,  142 

praecordial,  160 

throat,  141 

wet,  140 

rationale  of,  152 
therapeutics  of,  156 
Winternitz,  147 
Constipation,  476 

treatment,  481 
Cooling  apparatus,  398 
Cooling  deep  parts,  149 

Oilman  Thompson  on,  149 
Crisis  under  chest  compresses,  359, 365 
Currie,  pioneer  work,  526 
Curschman  on  Brand  method,  327 
Cystitis,  bath  in,  245 

DELIRIUM  TREMENS,  affusions  in,  113 

baths  in,  228 
Dementia  prsecox,  497 

insomnia  in,  497 


Diabetes,  425 

hydrotherapy  in,  425 
Diabetic  gangrene,  prolonged  bath  in, 

244 

Diagnostic  bath,  321,  331 
Diarrhoea,  chronic,  prolonged  bath  in, 

245 
Douche,  253 

forms  of,  254 

hot,  action  of,  257 

imperfect,  in  houses,  264 

in  clinics,  265 

perineal,  306 

rationale,  255 

table,  395 

technique,  255 

therapeutics  of,  263 
Drip  sheet,  118 

therapeutics  of,  122 
Dysentery,  amoebic,  irrigation  in,  293 

cold  irrigations  in,  297 
Dyspepsia,  forms  of,  471 

guides  to  treatment  in,  472-474 

hot  water  in,  317 

nervous,  279 

ECZEMA,  steam  in  obstinate,  312 
England,  hydrotherapy  in,  526 
Enteroclysis,  284 

diuretic  effect  of,  288 
Entero-colitis,  compresses  in,  370 

graduated  baths  in,  368 

irrigation  in,  367 

lavage  in,  367 

therapeutic  indications  in,  366 

wet  pack  in,  370 
Epilepsy,  hydrotherapy  in,  459 
Ergograph,  75 
Exanthemata,  baths  in,  335 
Exhaustion  psychoses,  496 

FLEURY,  experiments  of,  93 

Fodor  on  steam  in  skin  diseases,  312 

Fomentations,  hot,  159 

France,  hydrotherapy  in,  524 

Friction,  necessity  of,  165 

Frost  bite,  steam  in,  312 

GASTRALGIA,  lavage  in,  280 

Gastric  catarrh,  therapeutics  of,  318 


INDEX. 


541 


Germany,  hydrotherapy  in,  519 
Glax,  Prof.,  315 
Glycogen  in  the  skin,  425 
Goldenberg's  cooling  sound,  307 
Gout,  chronic,  management  of,  468 

HAHNEMANN  on  water  treatment,  519 
Half-bath,  108 

therapeutics  of,  109 
Hammock  bath,  324 
Heart  disease,  douche  in,  264 
Heart  failure,  affusion  in,  332 

cause  of,  180 

Paessler  on,  184 

Romberg  on,  180 
Heat,  effect  of,  56 

effect  on  blood  cells,  62 

effect  on  circulation,  56 

production,  effect  of  douches  on, 
262 

Wick  on  effect  of,  72 
Hip  bath,  rationale  of,  268 

technique  of,  267 

therapeutics  of,  269 
Hippocrates  on  hydrotherapy,  519 
History,  lessons  of,  531 

of  hydrotherapy,  518 
Hot-air  bath,  rationale  of,  388 
Hydriatic  applications,  effect  on  dis- 
tribution of  bloocl,  34 

hydrostatic  effect  of,  34 

influence  of,  34 
Hydropathy,  definition  of,  1 
Hydrotherapeutic  apparatus,  393 

law,  author's,  100 

institution,  394 

Hydrotherapy  among  the   ancients, 
519 

definition  of,  2 

faulty,  examples  of,  511, 514, 516 

for  insane,  legislation  on,  499 

Hahnemann  on,  519 

Hippocrates  on,  519 

in  Columbia  University,  536 

in  health  resorts,  530 

Kellogg  on,  532 

Kussmaul  on,  523 

Leyden  and  Klemperer  on,  523 

obligatory  study  of,  537 

Prof.  Brieger  on,  535 


Hydrotherapy,  Prof.  Crede'  on,  535 
Prof.  Vierordt  on,  534 
testimony  of  experts  on,  500-504 

Hyperpyrexia,  204 

Hypodermoclysis,  Sahli  on,  317 

Hysteria,  Charcot  douche  in,  454 
guides  to  treatment,  456-459 
Peterson  on  treatment,  481 
types  of,  treatment,  455 

ICE  bag,  149 
Ileus,  lavage  in,  282 
Illinois  State  Board  of  Charities  re- 
port to  legislature,  500 
Incurable  maladies,  prolonged  bath 

in,  243 

Insanity,  acute,  home  treatment,  493 
acute,  hydrotherapy  in,  493 
continuous  baths  in,  498 
Dent  on  guides    for  treatment 

of,  485-489 

Dent  on  value  of  baths,  484 
elimination  in,  492 
guides  to  hydrotherapy  in,  479- 

496 

hydrotherapy  in,  477 
in  Danvers  Hospital,  H.  W.  Mit- 
chell on,  490 
insomnia  in,  H.  W.  Mitchell  on, 

490 

maniacal  depressive,  best  treat- 
ment, 497 
Peterson    on    hydrotherapy    in, 

478 

renal  complications  in,  494-496 
summary  of  treatment,  409 
vaso-motor  tonic  in,  491 
Insolation,  379 
Insomnia,  Mitchell  on  treatment  of, 

490 

fallacy  of  standard  present  man- 
agement, statistical  proof  of, 
440  et  seq. 

Neptune  girdle  in,  158 
of  insane,  480 
treatment  in,  440 
warm  bath  in,  234 
Instruction  in  hydrotherapy,  533 
Intestinal  obstruction,  irrigation  in, 
294 


542 


INDEX. 


Irrigation,  272 

Irrigations,  field  of  action,  286 
Italy,  hydrotherapy  in,  524 
Ivy  poisoning,  hot  water  in,  239 

JAMES,  Prof.,  on  jaundice,  289 
Japanese  baths,  72 

KELLOGG  on  phthisis,  410 
Kemp,  R.  C.,  on  irrigation,  285 
Kemp's  vaginal  irrigation,  302 
Kemp's  vaginal  irrigator,  302 
Kidneys,  failure  of,  183 

treatment  of,  184 

Knoepfelmacher,  experiments  of,  59 
Kraepelin  on  prolonged  baths,  248 

LAVAGE,  272 

rationale  of,  276 
therapeutics  of,  273,  277 
Law,  hydrotherapeutic,  100 
Lead  colic,  treatment  of,  295 
Loomis,  H.  P.,  on  Brand  bath,  195 

MALARIAL  diseases,  hydrotherapy  in, 

427 

fever,  affusions  in,  431 
Mania,  480 
Mathes,  Prof.  M.,  99 
Mays'  ice  packs  in  pneumonia,  362 
Measles,   baths  in,  high  authorities 

for,  337 

hydrotherapy  of,  335,  338 
Melancholia,  482 
Meningitis,  affusions  in,  114 

cerebro-spinal,  warm    bath  in, 

236 

Menorrhagia,  hip  bath  in,  269 
Menstrual  disorders,  warm  bath  in, 

238 

Montefiore  Home,  cases  from,  418-456 
Miiller,  Ottfried,  49 
Muscles,  effect  of  cold  on,  76 

NATURARZTE,  inroads  of,  on  practice 

by,  522 

Nauheim  bath,  84 
Naumann,  experiments  of,  37 
Nephritis,  acute,  drinking  water  in, 

319 


Nephritis,  in  typhoid  fever,  226 
Kussmaul  on,  341 
of  scarlatina,  tepid  baths  in,  342 
of  scarlatina,  warm  baths  in,  340 
prolonged  baths  in,  248 
scarlatina,  wet  pack  in,  341 

Neptune  girdle,  146 

Neuralgia,  447 

Neurasthenia,  guides  to  hydrother- 
apy in,  443-446 
G.  W.  Foster  on,  496 
symposium  on,  432,  433 
types  of  treatment,  434 

Northrup,  Prof.,  on  typhoid  fever, 
196 

Nutrition,  improvement  of,  413,  494 

OBESITY,  hot-air  bath  in,  391 
Obstinate  cases,  management  of,  517 
Osier  on  baths  in  typhoid  fever,  527 

PARALYSIS,     general,     examples    of 

treatment,  481 

Perforation  in  typhoid  fever,  226 
Pernicious  anaemia,  irrigation  in,  294 
Phthisis,  control  experiment  in,  423 

hydrotherapy  in,  410 

striking  results  in,  416-421 
Plethysmograph,  48 
Pneumonia,  chest  compress  in,  355 

clinical  results  in,  360 

fresh  air  in,  347 

ice  packs  in,  362 

management  of,  353 

Striimpell  on  tepid  baths  in,  353, 

354 

Pneumonia,  catarrhal,  361 
Pneumonia  of  children,  349 

Baginski  on,  351 

cool  baths  in,  350 

Jacobi  on,  350 

Pneumonia  of  infants,  A.  Jacobi  on 
baths  in,  509 

danger  of  cold  baths  in,  510 
Polyarthritis,  bath  in,  251 
Prescription,  hydriatric,  506 

of  water,  errors  in,  508 
Prolonged  bath,  apparatus  for,  240 

in  burns,  244 

rationale  of,  241 


INDEX. 


543 


Prolonged  bath,   Riess  on,  241 

surgery  in,  252 

therapeutics  of,  242 
Prostate  hypertrophy,  irrigation  for, 

302 

Prostatic  cooler,  304 
Prostatitis,  irrigation  in,  296 

QUACKS,  inroads  of,  522 

REACTION,  96 
test  of,  102 

Respiration,  effect  of  water  on,  71 

Respiratory  gas  exchange,  73 

Rheumatism,  hot-air  bath  in,  392 
chronic,  462 

douche-massage  in,  466 
mineral  springs  in,  462 
Scotch  douche  in,  464 
Turkish  bath  in,  467 
types  of,  467 
warm  bath  in,  235 
muscular,  management  of,  468 

Rheumatoid  arthritis,  469 

Ritter,  experiments  of,  54 

Rubner  on  hot  baths,  73 

SCARLATINA,  affusions  in,  112 

baths  in,  339 

continuous  bath  in,  344 

nervous  symptoms  in,  339 

of  adults,  cold  baths  in,  343 
Schuller.  experiments  of,  41 
Sciatica,  management  of,  450-452 

treatment  in,  453 
Scotch  douche,  259 
Severe  burns,  value  of  prolonged  bath 

in,  244 
Sheet  bath,  115 

in  fever,  117 

Sihler  on  Brand  baths,  201 
Skin,  anatomy  and  physiology  of,  4 

an  organ  of  excretion,  25 

as  heat  regulator,  27 

blood-vessels  of,  6 

function  of,  23 

heart,  Hutchinson's,  8 

nerves  of,  16 

normal  temperature  of,  99 

reflex  areas  of,  19 


Skin,  temperature  of,  20 

temperature  sensation  of,  23 

veins  of,  16 

Skin  diseases,  steam  in,  312 
Sphygmograph,  51 
Sprains,  hot  water  in,  252 
Statistics  of  cold  baths,  202 
Steam,  apparatus  for  applying,  309, 
310 

as  a  styptic,  308 

use  of,  307 
Stomach  atony,  lavage  in,  278 

dilatation  of,  279 

diseases,  test  lavage  in,  474 

lavage  of,  279 
Strasser,  A.,    experiments   with   on- 

kometer,  67 
Sunstroke,  379 

correct  treatment  in,  385 

fatality  of  ice  baths,  383 

Osier  on,  380 

therapeutic  statistics  of,  384 

TEMPERATURE  in  health,  90 
Thayer,  S.,  experiments  of,  57 
Tissue  change,  effect  of  temperature, 
79 

Strasser  on,  83 

Toxaemia,  enteroclysis  in,  295 
Turck,  F.  B.,  on  gastric  douche,  275 
Typhoid  fever,  ablution  in,  327 

Barr  on,  248 

bedsores  in,  226 

Cabot  on  baths  in,  328 

clinical  histories  of,  327 

COa  bath  in,  333 

cold  baths  in,  202 

F.  H.  Hare  on,  199 
Hobart  Hare  on,  199 

continuous  baths  in,  331 

desperate  case  of,  330 

high  temperature  in,  204 

hydrotherapy  of,  321 

ice  rub  in,  325 

in  Australia,  326 

Musser,  Prof.,  on,  196 

nephritis  in,  226 

perforation  in,  226 

private    and    hospital    practice, 
333 


544 


INDEX. 


Typhoid  fever,  prolonged  bath  in,  245 
Riess  on,  246 
sheet  bath  in,  117 
Tyson,  Prof.,  on,  194 
Smythe  on,  194 
wet  pack  in,  324 

UREA,  effect  of  temperature  on  excre- 
tion of,  85 

VAGINAL  irrigation,  technique  of,  302 

therapeutics  of,  303 
Variola,  baths  in,  342 
Vinaj,  experiments  of,  47 
Vogl,  A.,  statistics  of,  206 

WARM  bath,  definition  of,  233 

therapeutics  of,  234 
Warm  full  bath,  229 

in  cardiac  disease,  235 

technique  of,  229 

rationale  of  230 
Water,  contraindications  to,  319 


Water,  internal  use  of,  314 

physical  properties  of,  31 

physiological  effect  of,  3 

rationale  of  action,  34 

treatment,  precision  needed,  513 

useful  remedy,  Hahnemann  on, 
519 

Winternitz  on,  3 
Wet  compress,  140 
Wet  pack,  Groedel  on,  135 

in  insanity,  139 

in  nephritis,  137 

Putnam-Jacobi  on,  135 

rationale  of,  124,  127 

therapeutics  of,  132 

Van  Noorden  on,  135 
'Winternitz,  H.,  studies  on  baths,  262 

op  gas  exchange,  73 
Winternitz,  Wilhelm,    pioneer  of  hy- 

drotherapy,  520 
Woods-Hutchinson  on  Brand  bath,  82 

ZIEMSSEN,  graduated  bath  of,  172 


of  California 


from  which  it  was  borrowed. 


N  REGIONAL  LIBRARY  FACjjJ™ 


000510245  4 


Baruch,  Simon. 

Principles  and  practice 


WB520 
B295p 
1908 

hydrotherapy 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


